C55 Insurance Policy Changes

ICD-10 C55 is officially defined as "Malignant neoplasm of uterus, part unspecified." code C55 is referenced in 18 tracked payer policy changes from Independence Blue Cross, Blue Cross Blue Shield of North Dakota, and 1 other payer. For billers and coders, staying current on payer-specific coverage criteria, reimbursement rules, and prior-authorization requirements for code C55 is critical to clean claim submission. Each entry below links to the full policy analysis with effective dates and action steps.

Independence Blue Cross · Effective Dec 29, 2025High impact
08.01.33l, Leuprolide (Camcevi™, Eligard®, Fensolvi®, Lupron Depot®)
Independence Blue Cross updated Leuprolide policy 08.01.33l to version 08.01.33n, adding coverage for uterine neoplasms, revising prostate cancer and head/neck cancer criteria per NCCN guidelines, and introducing Camcevi ETM 21 mg (3-month formulation). Specific ICD-10 codes for inflammatory breast cancer and uterine malignancies were added or modified with different coverage rules by formulation. The preferred product designation remains leuprolide acetate (Eligard/Lupron Depot J9217) for prostate cancer and salivary gland tumors, with nonpreferred products (Camcevi, Camcevi ETM, Lupron Depot J1950) covered only for current/prior users or those with contraindications/intolerances.
Blue Cross Blue Shield of North Dakota · Identified Jun 19, 2026High impact
Pharmacy Policy Updates
Blue Cross Blue Shield of North Dakota revised many Commercial prior authorization drug policies, with revisions effective April 14, 2026, including oncology drugs such as Adcetris, Keytruda IV, Keytruda SQ, Opdivo IV, Opdivo SQ, Darzalex IV and Trodelvy. The same notice lists Commercial post service claim edit policy revisions effective March 1, 2026 for Aranesp, Epoetin alfa and Mircera, and Commercial medical drug coding updates effective April 1, 2026 with new, removed and changed HCPCS codes.
Blue Cross Blue Shield of North Dakota · Effective Sep 9, 2026Medium impact
Pharmacy Policies Available Online
Blue Cross Blue Shield of North Dakota updated its commercial pharmacy policies, and the revisions to the commercial prior authorization medical drug policies are effective September 9, 2026. Revisions to the commercial post service claim edit medical drug policies are effective August 1, 2026. Many of the prior authorization policies now state the number of days allowed for initial and renewal authorization durations, replace specific contraindications in the Universal Criteria with general language that the member does not have any FDA contraindications, and add covered ICD-10 diagnosis codes in Appendix 1.
Blue Cross Blue Shield of North Dakota · Effective Mar 17, 2026Medium impact
Pharmacy Policies Available Online
Commercial prior authorization medical drug policies have revisions effective March 17, 2026, with many policies adding the Appendix A NQTL Factor Checklist, showing the number of days allowed for authorization durations, and replacing 'coverage' with 'prior authorization validity' in the initial and renewal criteria. Clinical updates include Eylea HD for macular edema following retinal vein occlusion, Breyanzi for relapsed or refractory marginal zone lymphoma, and new appendiceal neoplasm and cancer indications with ICD-10 codes D37.3 and Z85.038. Commercial post service claim edit policies for Trogarzo have revisions effective Feb. 1, 2026.
Independence Blue Cross · Effective Dec 29, 2025Medium impact
MA08.083l, Leuprolide (Camcevi™, Eligard®, Fensolvi®, Lupron Depot®)
Independence Blue Cross updated MA08.083l to MA08.083n effective 12/29/2025, adding coverage for uterine neoplasms, revising prostate cancer and head/neck cancer criteria per NCCN guidelines, adding the new Camcevi ETM 21 mg 3-month formulation, and modifying ICD-10 code coverage to specify laterality for breast inflammatory neoplasms. The preferred product designation remains leuprolide acetate (Eligard and Lupron Depot 7.5 mg, J9217) for prostate cancer and salivary gland tumors.
Aetna · Identified Oct 18, 2026Medium impact
Gonadotropin-Releasing Hormone Analogs and Antagonists (CPB 0501, reviewed 2026-10-14)
Aetna considers gonadotropin-releasing hormone (GnRH) analogs and antagonists medically necessary for commercial plan members only for the specific indications listed for each drug, including leuprolide, goserelin, histrelin, triptorelin, degarelix, cetrorelix and ganirelix, and treats all other indications as experimental, investigational or unproven. Each drug has separate criteria for initial approval and for continuation of therapy, and continuation for prostate cancer requires clinical benefit such as serum testosterone less than 50 ng/dL and no unacceptable toxicity. Precertification is required for the prostate cancer indication, and gender dysphoria treatment for members under 18 must be prescribed by or in consultation with a provider specialized in the care of transgender youth who has collaborated care with a mental health provider.
Aetna · Identified Oct 15, 2026Medium impact
Avelumab (Bavencio) (CPB 0916, reviewed 2026-10-14)
Aetna considers avelumab (Bavencio) medically necessary for commercial plan members with Merkel cell carcinoma, renal cell carcinoma in combination with axitinib, urothelial carcinomas, gestational trophoblastic neoplasia, endometrial carcinoma, thymic carcinoma, extranodal NK/T-cell lymphoma, colorectal adenocarcinoma, and small bowel adenocarcinoma when the criteria for each indication are met. Precertification of avelumab is required for all Aetna participating providers and members in applicable plan designs, and members who have experienced disease progression while on PD-1 or PD-L1 inhibitor therapy are not eligible. Aetna considers avelumab experimental, investigational, or unproven for all other indications, including breast cancer, non-small cell lung cancer, ovarian cancer, prostate cancer, and pancreatic cancer.
Aetna · Identified Oct 13, 2026Medium impact
Temsirolimus (Torisel) (CPB 0873, reviewed 2026-10-08)
Aetna's Clinical Policy Bulletin 0873 considers temsirolimus (Torisel or generic temsirolimus) medically necessary as a single agent for subsequent treatment of locally advanced, recurrent or metastatic endometrial carcinoma, for relapsed or refractory mantle cell lymphoma, and for advanced renal cell carcinoma, along with specified soft tissue sarcoma and uterine sarcoma subtypes. The covered sarcoma uses are locally advanced unresectable or metastatic perivascular epithelioid cell tumor (PEComa), recurrent angiomyolipoma or lymphangioleiomyomatosis, and rhabdomyosarcoma (maximum 12 cycles, given with cyclophosphamide and vinorelbine). Aetna considers temsirolimus experimental, investigational or unproven for all other indications, including acute lymphoblastic leukemia, breast cancer, colorectal cancer, melanoma, multiple myeloma and prostate cancer, and for endovascular treatment of below-the-knee atherosclerotic lesions.
Aetna · Identified Aug 19, 2026Medium impact
Brachytherapy (CPB 0371, reviewed 2026-05-20)
Aetna considers brachytherapy medically necessary for breast, esophageal, eye tumors, genitourinary cancers other than bladder, gynecologic, head and neck, respiratory and digestive tract, and soft tissue sarcoma indications when the EviCore Healthcare Radiation Therapy Clinical Guidelines criteria are met. It also considers brachytherapy medically necessary for skin cancer where surgical resection and photon or electron beam techniques are contraindicated, and for stenotic obstruction after lung transplantation refractory to other treatments. Brachytherapy for bladder cancer, bone metastases, brain tumors, leukemia, lymphoma, multiple myeloma, pancreatic cancer, keloids, palmoplantar pustulosis, spinal tumors and spinal metastases, and subfoveal choroidal neovascularization secondary to age-related macular degeneration is considered experimental, investigational or unproven, and electronic brachytherapy is considered experimental, investigational or unproven for breast cancer and all other indications.
Aetna · Identified Aug 18, 2026Medium impact
Trastuzumab Products (CPB 0313, reviewed 2026-06-08)
Aetna Clinical Policy Bulletin 0313 sets coverage rules for trastuzumab products for commercial medical plans, including Herceptin and the biosimilars Hercessi, Herzuma, Kanjinti, Ogivri, Ontruzant and Trazimera. Aetna considers these products medically necessary for HER2-positive breast cancer in the adjuvant, neoadjuvant and metastatic settings, for HER2-positive esophageal, gastric, biliary, salivary gland, small bowel, appendiceal and uterine serous cancers, and for HER2-positive, RAS and BRAF wild-type colorectal cancer when the listed criteria are met. Aetna considers all other indications experimental, investigational or unproven, including lung, ovarian, pancreatic, prostate, bladder and melanoma, and considers lapatinib plus trastuzumab and pertuzumab plus trastuzumab for HER2-positive breast cancer experimental, investigational or unproven.
Aetna · Identified Aug 18, 2026Medium impact
Trabectedin (Yondelis) (CPB 0903, reviewed 2026-01-13)
Aetna covers trabectedin (Yondelis) for commercial medical plans when the criteria for the listed sarcoma indications are met. Covered indications include advanced, recurrent/metastatic or inoperable leiomyosarcoma (first-line in combination with doxorubicin, or second-line or later as a single agent), certain soft tissue sarcomas, pleomorphic rhabdomyosarcoma, solitary fibrous tumor, dedifferentiated liposarcoma and epithelioid hemangioendothelioma. Continuation of trabectedin is medically necessary for a listed indication while there is no evidence of unacceptable toxicity or disease progression on the current regimen, and all other indications are considered experimental, investigational or unproven. This is dated 2026-01-13, so check current applicability before acting.
Aetna · Identified Aug 18, 2026Medium impact
Temsirolimus (Torisel) (CPB 0873, reviewed 2025-10-09)
Aetna considers temsirolimus (Torisel or generic temsirolimus) medically necessary as a single agent for subsequent treatment of locally advanced, recurrent, or metastatic endometrial carcinoma, for relapsed or refractory mantle cell lymphoma, and for advanced renal cell carcinoma. It also considers it medically necessary for specified soft tissue sarcoma subtypes, for rhabdomyosarcoma (maximum 12 cycles, with cyclophosphamide and vinorelbine), and for subsequent treatment of advanced, recurrent/metastatic, or inoperable PEComa in uterine sarcoma. Aetna considers all other indications experimental, investigational, or unproven, and considers continuation of therapy medically necessary when there is no evidence of unacceptable toxicity or disease progression while on the current regimen.
Aetna · Identified Aug 17, 2026Medium impact
Temozolomide (Temodar) Injection (CPB 0876, reviewed 2026-06-03)
Aetna's Clinical Policy Bulletin 0876 considers temozolomide (Temodar) injection medically necessary for brain metastases from solid tumors, metastatic or unresectable cutaneous melanoma as single agent subsequent therapy, second-line Ewing sarcoma in combination with irinotecan with or without vincristine, mycosis fungoides or Sezary syndrome with CNS involvement as single agent subsequent therapy, high-risk neuroblastoma in combination with irinotecan, dinutuximab and sargramostim or with irinotecan, naxitamab-gqgk and sargramostim, unresectable or metastatic pheochromocytoma or paraganglioma as single agent first-line therapy, relapsed or primary progressive small cell lung cancer as single agent subsequent therapy, advanced, recurrent, metastatic or inoperable uterine sarcoma as single agent subsequent therapy, and unresectable or metastatic uveal melanoma as a single agent. Aetna considers all other indications experimental, investigational or unproven, including chronic lymphocytic leukemia, diffuse large B-cell lymphoma, metastatic colorectal cancer and pituitary tumors. Continuation of therapy is considered medically necessary when there is no evidence of unacceptable toxicity or disease progression on the current regimen.
Aetna · Identified Aug 15, 2026Medium impact
Ipilimumab (Yervoy) (CPB 0815, reviewed 2026-07-16)
Aetna's Clinical Policy Bulletin 0815 covers ipilimumab (Yervoy) for commercial medical plans. It considers ipilimumab medically necessary for the cancer indications listed in the policy, many of them in combination with nivolumab, and considers continued treatment medically necessary for members requesting reauthorization when there is no evidence of unacceptable toxicity or disease progression. It considers ipilimumab experimental, investigational, or unproven for indications such as glioblastoma, pancreatic cancer, and prostate cancer, and for use with bevacizumab, vemurafenib, dabrafenib, or trametinib.
Aetna · Identified Aug 15, 2026Medium impact
Gonadotropin-Releasing Hormone Analogs and Antagonists (CPB 0501, reviewed 2026-07-10)
Aetna covers gonadotropin-releasing hormone (GnRH) analogs and antagonists under its commercial medical plans for the indications the policy lists, including prostate cancer, breast cancer, ovarian cancer, central precocious puberty, endometriosis, uterine leiomyomata (fibroids), and ovulation induction or assisted reproductive technology. The policy also sets criteria for gender dysphoria treatment, including pubertal suppression in adolescents and gender transition, and for continuation of therapy. Aetna considers all other indications experimental, investigational, or unproven.
Aetna · Identified Aug 13, 2026Medium impact
Pemetrexed Products (CPB 0687, reviewed 2026-07-17)
Aetna considers pemetrexed (Alimta, Axtle, Pemfexy, Pemrydi RTU, or generic pemetrexed) medically necessary for commercial members with the listed indications: non-squamous non-small cell lung cancer, pleural and peritoneal mesothelioma, ovarian, fallopian tube and primary peritoneal cancer, cervical cancer, bladder cancer, primary CNS lymphoma, thymoma and thymic carcinoma, thyroid cancer, and vaginal cancer. Members with squamous cell non-small cell lung cancer are not eligible, and indications such as breast, colorectal, gastric, pancreatic and small cell lung cancer are experimental, investigational, or unproven. Continuation is covered when there is no unacceptable toxicity or disease progression, and use with pembrolizumab for pleural or peritoneal mesothelioma is covered for up to 24 months total.
Aetna · Identified Aug 13, 2026Medium impact
Dostarlimab-gxly (Jemperli) (CPB 0993, reviewed 2026-01-27)
For commercial medical plan members, Aetna considers dostarlimab-gxly (Jemperli) medically necessary under its initial approval criteria for several mismatch repair deficient or microsatellite instability-high cancers, including endometrial, ampullary, breast, colorectal, esophageal, gastric, ovarian, pancreatic, small bowel and anal cancers. It also considers Jemperli in combination with pemetrexed and platinum chemotherapy for first-line metastatic nonsquamous non-small cell lung cancer without genomic aberrations. Members are not eligible when they have experienced disease progression while on PD-1 or PD-L1 inhibitor therapy, and all other indications are considered experimental, investigational, or unproven.
Aetna · Identified Aug 12, 2026Medium impact
Avelumab (Bavencio) (CPB 0916, reviewed 2025-10-09)
Aetna's criteria cover avelumab (Bavencio) for Merkel cell carcinoma as a single agent; first-line advanced renal cell carcinoma with clear cell histology in combination with axitinib; urothelial carcinomas (bladder cancer, primary carcinoma of the urethra, upper genitourinary tract tumors, and urothelial carcinoma of the prostate) as subsequent therapy or as maintenance therapy when there is no progression on first-line platinum-containing chemotherapy; gestational trophoblastic neoplasia; recurrent endometrial carcinoma (as a single agent when MSI-H or dMMR, or with axitinib when pMMR); thymic carcinoma with axitinib; relapsed or refractory extranodal NK/T-cell lymphoma; and colorectal or small bowel adenocarcinoma that is dMMR/MSI-H or POLE/POLD1 ultra-hypermutated, as a single agent or as neoadjuvant treatment of up to 6 months. Members who have experienced disease progression while on PD-1 or PD-L1 inhibitor therapy are not eligible, and all other indications are considered experimental, investigational or unproven. This policy addresses avelumab for commercial medical plans, where precertification is required and the Site of Care Utilization Management Policy applies.

Watch C55

Get one email when a payer policy names C55, a payer adds or drops it from a prior auth list, or Medicare changes its NCCI pairs, unit limit, payment or coverage articles.

No account needed. We send a confirmation link first, and every email has a one-click stop link.

FREQUENTLY ASKED QUESTIONS

What insurance policy changes affect code C55?

There are 18 tracked policy changes affecting code C55, including updates from Independence Blue Cross, Blue Cross Blue Shield of North Dakota, Aetna. Each change may modify coverage criteria, reimbursement rates, or prior-authorization requirements.

Which payers have updated policy for code C55?

Payers that have issued tracked updates for code C55 include: Independence Blue Cross, Blue Cross Blue Shield of North Dakota, Aetna.

How do I get notified when code C55 policy changes?

Create a free account at PolicyChanges.app and save a search filtered to code C55. You will get an email when new policy changes reference this code: daily or weekly, your choice, on every plan.

Why do payers change policies for code C55?

Payers revise policies for individual billing codes to align with updated clinical guidelines, CMS rule changes, fraud and abuse prevention measures, or network cost-management goals. Changes can affect medical necessity criteria, place-of-service restrictions, bundling rules, or whether a code requires prior authorization.

All billing codes J3590 C9399 J3490 99215 99213 99202

Get alerts for changes like this

Save a search and get email alerts when a new policy change matches your filters: daily or weekly, your choice, on every plan.

Create a free alert How Policy Monitoring works

08.01.33l, Leuprolide (Camcevi™, Eligard®, Fensolvi®, Lupron Depot®)

Pharmacy Policy Updates

Pharmacy Policies Available Online

Pharmacy Policies Available Online

MA08.083l, Leuprolide (Camcevi™, Eligard®, Fensolvi®, Lupron Depot®)

Gonadotropin-Releasing Hormone Analogs and Antagonists (CPB 0501, reviewed 2026-10-14)

Avelumab (Bavencio) (CPB 0916, reviewed 2026-10-14)

Temsirolimus (Torisel) (CPB 0873, reviewed 2026-10-08)

Brachytherapy (CPB 0371, reviewed 2026-05-20)

Trastuzumab Products (CPB 0313, reviewed 2026-06-08)

Trabectedin (Yondelis) (CPB 0903, reviewed 2026-01-13)

Temsirolimus (Torisel) (CPB 0873, reviewed 2025-10-09)

Temozolomide (Temodar) Injection (CPB 0876, reviewed 2026-06-03)

Ipilimumab (Yervoy) (CPB 0815, reviewed 2026-07-16)

Gonadotropin-Releasing Hormone Analogs and Antagonists (CPB 0501, reviewed 2026-07-10)

Pemetrexed Products (CPB 0687, reviewed 2026-07-17)

Dostarlimab-gxly (Jemperli) (CPB 0993, reviewed 2026-01-27)

Avelumab (Bavencio) (CPB 0916, reviewed 2025-10-09)

What insurance policy changes affect code C55?

Which payers have updated policy for code C55?

How do I get notified when code C55 policy changes?

Why do payers change policies for code C55?