C76.0 Insurance Policy Changes

ICD-10 C76.0 is officially defined as "Malignant neoplasm of head, face and neck." code C76.0 is referenced in 21 tracked payer policy changes from Aetna and Blue Cross & Blue Shield of Mississippi. For billers and coders, staying current on payer-specific coverage criteria, reimbursement rules, and prior-authorization requirements for code C76.0 is critical to clean claim submission. Each entry below links to the full policy analysis with effective dates and action steps.

Aetna · Identified Nov 4, 2026Medium impact
Nivolumab Products (Opdivo, Opdivo Qvantig, and Opdualag) (CPB 0892, reviewed 2026-10-28)
Aetna's clinical policy bulletin CPB 0892, last reviewed 2026-10-28, sets the coverage criteria for nivolumab (Opdivo), nivolumab and hyaluronidase-nvhy (Opdivo Qvantig), and nivolumab and relatlimab-rmbw (Opdualag) for Aetna commercial medical plans, including indication-by-indication initial approval criteria, continuation-of-therapy criteria, and dosing references. Precertification is required for all three products, and the site-of-care utilization management policy applies. The practice's billing team should align charge entry, precertification tracking, and documentation with the indications and continuation limits listed for each product.
Aetna · Identified Oct 22, 2026Medium impact
Intraoperative Radiation Therapy (IORT) (CPB 0721, reviewed 2026-10-15)
Aetna Clinical Policy Bulletin 0721 sets Aetna's coverage rules for intraoperative radiation therapy (IORT). Aetna considers IORT medically necessary for cervical cancer, colorectal cancer, soft tissue sarcoma (including retroperitoneal sarcoma) and uterine cancer, and considers single-fraction electron-beam IORT at the time of lumpectomy medically necessary for breast cancer when the selection criteria are met. Aetna considers IORT experimental, investigational or unproven for brain tumors and brain metastasis, cholangiocarcinoma, conjunctival neoplasms, gastric cancer, glioma, head and neck cancers, osteosarcoma, pancreatic cancer, prostate cancer, renal cell carcinoma, spinal and vertebral metastases, sporadic renal angiomyolipoma and thymoma, and notes that this list is not all-inclusive.
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 8, 2026Medium impact
Docetaxel (CPB 0956, reviewed 2026-10-05)
For commercial medical plans, docetaxel (Beizray, Docivyx, Taxotere, or generic docetaxel) is considered medically necessary for the listed cancer indications, including breast cancer, non-small cell lung cancer, prostate cancer, gastric cancer, head and neck cancer, ovarian cancer, small cell lung cancer, and soft tissue sarcoma. Breast cancer requires the disease-status criteria stated in the policy, and continuation of therapy is considered medically necessary when there is no evidence of unacceptable toxicity or disease progression on the current regimen. All other indications are considered experimental, investigational, or unproven.
Aetna · Identified Sep 30, 2026Medium impact
Durvalumab (Imfinzi) (CPB 0917, reviewed 2026-09-25)
Aetna covers durvalumab (Imfinzi) for commercial medical plans and considers it medically necessary for the listed cancer indications when that indication's criteria are met, including lung, small cell lung, biliary tract, cervical, colorectal, ampullary, pleural mesothelioma, hepatocellular, gastric, GEJ, esophageal, endometrial, bladder, and small bowel cancers. Members who have experienced disease progression while on PD-1 or PD-L1 inhibitor therapy are not considered eligible, and Aetna considers all other indications experimental, investigational, or unproven. Continuation of therapy is covered under separate reauthorization criteria that require no evidence of unacceptable toxicity or disease progression, with stated limits such as up to 12 months for unresectable stage II or III NSCLC and up to 24 months total for limited stage SCLC.
Aetna · Identified Aug 19, 2026Medium impact
Intraoperative Radiation Therapy (IORT) (CPB 0721, reviewed 2025-10-20)
Aetna considers intraoperative radiation therapy (IORT) medically necessary for cervical cancer, colorectal cancer, soft tissue sarcoma (including retroperitoneal sarcoma), and uterine cancer, and considers single-fraction electron-beam IORT at the time of lumpectomy medically necessary for breast cancer when the selection criteria are met. For breast cancer, the criteria are a documented diagnosis of early stage (0, I or II) breast cancer, negative lymph nodes, technically clear surgical margins, and a tumor less than or equal to 5 cm in diameter. IORT is considered experimental, investigational, or unproven for brain tumors and brain metastasis, cholangiocarcinoma, conjunctival neoplasms, gastric cancer, glioma, head and neck cancers, osteosarcoma, pancreatic cancer, prostate cancer, renal cell carcinoma, spinal metastases, sporadic renal angiomyolipoma, thymoma, and vertebral metastases (the list is not all-inclusive).
Aetna · Identified Aug 16, 2026Medium impact
Irreversible Electroporation (NanoKnife) (CPB 0828, reviewed 2026-03-03)
This is an older Aetna clinical policy bulletin (CPB 0828) on irreversible electroporation (IRE), including the NanoKnife system for tissue ablation. It was last reviewed 03/03/2026, and its original effective date is 06/15/2012. Aetna considers IRE experimental, investigational or unproven for all indications, including the listed indications such as hepatocellular carcinoma, pancreatic cancer, prostate cancer, renal masses, lung nodules and breast cancer, because the peer-reviewed literature has insufficient evidence.
Aetna · Identified Aug 16, 2026Medium impact
Necitumumab (Portrazza) (CPB 0898, reviewed 2026-07-02)
Aetna's commercial policy covers necitumumab (Portrazza) as medically necessary for metastatic squamous non-small cell lung cancer when it is used with gemcitabine and cisplatin. All other indications are considered experimental, investigational, or unproven, including colorectal cancer, head and neck squamous cell carcinoma, and non-squamous NSCLC. Continuation of therapy is medically necessary when there is no evidence of unacceptable toxicity or disease progression on the current regimen.
Aetna · Identified Aug 15, 2026Medium impact
Ramucirumab (Cyramza) (CPB 0883, reviewed 2026-06-03)
Aetna requires precertification for ramucirumab (Cyramza) for all participating providers and members in applicable commercial plan designs. Aetna considers ramucirumab medically necessary for gastric, gastro-esophageal junction, and esophageal adenocarcinoma in members who are not surgical candidates or have unresectable locally advanced, recurrent or metastatic disease, and for NSCLC, advanced colorectal cancer with FOLFIRI or irinotecan, hepatocellular carcinoma with AFP of at least 400 ng/mL, mesothelioma with gemcitabine, and thymic carcinoma in the specified carboplatin and paclitaxel settings. Aetna considers ramucirumab experimental, investigational, or unproven for other indications, including breast, ovarian, prostate and renal cell cancers, head and neck cancer, melanoma and rheumatoid arthritis.
Aetna · Identified Aug 15, 2026Medium impact
Cerebral Perfusion Studies (CPB 0663, reviewed 2026-04-14)
Aetna considers CT perfusion studies of the brain medically necessary for evaluating acute stroke (less than 24 hours), including hemorrhagic stroke, subdural hemorrhage and transient ischemic attacks, for following up cerebral ischemia or infarction, for planning therapy for cervical or intracranial arterial occlusive disease, for identifying cerebral hyperperfusion after revascularization, and for evaluating the vascular status of solid tumors when MRI is degraded by susceptibility artifact. Aetna considers MRI perfusion studies medically necessary for diagnosing and following mass lesions such as glioma, for assessing acute stroke penumbra, and for assessing the hemodynamic significance of cervical or intracranial vascular stenosis and the efficacy of revascularization. Aetna considers CT perfusion experimental, investigational or unproven for indications including confirmation of brain death, differentiation of lung cancer from benign lesions, evaluation of head trauma and evaluation of cerebral vasospasm, and considers MRI perfusion unproven for indications including evaluation of traumatic brain injury, evaluation of persistent pain and prognostication of obstructive sleep apnea.
Aetna · Identified Aug 15, 2026Medium impact
Carbogen Inhalation Therapy (CPB 0428, reviewed 2026-07-09)
Carbogen inhalation therapy (5% carbon dioxide and 95% oxygen) is considered experimental, investigational, or unproven for bladder cancer, central retinal artery occlusion, cervical cancer, fracture healing, head and neck cancers, optic nerve damage or degeneration, prostate cancer, retinal artery occlusion, seizures, stroke, and sudden hearing loss. The policy lists no specific CPT or HCPCS code for carbogen inhalation therapy, and the ICD-10 diagnosis codes for these indications are listed as not covered for carbogen inhalation therapy. The policy was last reviewed 07/09/2026.
Aetna · Identified Aug 14, 2026Medium impact
Jaw Motion Rehabilitation Systems (CPB 0412, reviewed 2026-06-30)
Aetna considers jaw motion rehabilitation systems, such as the Therabite Jaw Motion Rehabilitation System and the OraStretch press, medically necessary to treat mandibular hypomobility caused by radiation in persons with head and neck cancers. These systems are considered experimental, investigational, or unproven for all other indications, including trismus, closed lock, orofacial pain, non-surgical temporomandibular joint dysfunction, stroke, and Treacher Collins syndrome. Some plans exclude coverage of jaw stretch devices as equipment available over the counter without a prescription.
Aetna · Identified Aug 14, 2026Medium impact
Dental Services and Oral and Maxillofacial Surgery: Coverage Under Medical Plans (CPB 0082, reviewed 2026-03-18)
Aetna medical plans generally exclude routine dental care. Indemnity, PPO and Managed Choice plans generally cover certain oral and maxillofacial surgery services related to the jaw or facial bones, such as surgery to alter the jaw or bite when non-surgical management cannot produce functional improvement, removal of cysts and tumors, and surgical removal of teeth that will not erupt or are impacted in the bone. Pediatric orthodontics is covered only under a pediatric oral health benefit for a severe handicapping malocclusion related to a qualifying medical condition. Bone grafts into extraction sites are considered not medically necessary, except for impacted third molar extraction sites when bony defects are clinically significant and the patient is 26 years of age or older.
Aetna · Identified Aug 14, 2026Medium impact
Dendritic Cell Immunotherapy (CPB 0377, reviewed 2026-05-26)
Aetna considers dendritic cell immunotherapy experimental, investigational, or unproven because the peer-reviewed medical literature does not support its clinical use at this time, and there is no specific CPT or HCPCS code for it. ICD-10 codes for malignant neoplasms (leukemia, lymphoma, melanoma and solid tumors) and for melanoma in situ are listed as not covered for the indications in this bulletin. Current evidence is described as anecdotal, and randomized trials are needed to establish the appropriate antigen, adjuvant, dose, route and schedule.
Aetna · Identified Aug 13, 2026Medium impact
Docetaxel (CPB 0956, reviewed 2025-12-04)
Aetna considers docetaxel (Beizray, Docivyx, Taxotere or generic docetaxel) medically necessary for the cancers listed in the policy, including breast cancer, non-small cell lung cancer, prostate cancer, gastric and esophageal cancers, head and neck cancer, bladder cancer, soft tissue sarcoma, uterine neoplasms and others, and considers continuation medically necessary when there is no evidence of unacceptable toxicity or disease progression on the current regimen. Aetna considers all other indications experimental, investigational or unproven.
Aetna · Identified Aug 13, 2026Medium impact
Durvalumab (Imfinzi) (CPB 0917, reviewed 2026-06-25)
Aetna considers durvalumab (Imfinzi) medically necessary for commercial medical plans when the criteria for a listed indication are met, and considers all other indications experimental, investigational, or unproven. Precertification is required of all Aetna participating providers and members in applicable plan designs, and Aetna considers members not eligible for Imfinzi when they have experienced disease progression while on PD-1 or PD-L1 inhibitor therapy. Continuation of therapy is medically necessary when there is no evidence of unacceptable toxicity or disease progression on the current regimen, up to 12 months total for unresectable stage II or III NSCLC and up to 24 months total for limited stage SCLC.
Aetna · Identified Aug 13, 2026Medium impact
Paclitaxel, Albumin-Bound (CPB 0834, reviewed 2026-05-28)
Aetna considers albumin-bound paclitaxel (Abraxane or generic albumin-bound paclitaxel) medically necessary for the cancers listed in its initial approval criteria, including Kaposi sarcoma, breast cancer, cutaneous melanoma, endometrial carcinoma, ovarian, fallopian tube and primary peritoneal cancer, biliary tract cancers, non-small cell lung cancer, pancreatic adenocarcinoma, small bowel adenocarcinoma, uveal melanoma, ampullary adenocarcinoma, cervical cancer, bladder cancer and vaginal cancer, when each cancer's stated criteria are met. All other indications are considered experimental, investigational, or unproven, including small cell lung cancer, prostate cancer, soft-tissue sarcoma and gastric cancer. Continuation of therapy is medically necessary for an approved indication when there is no evidence of unacceptable toxicity or disease progression on the current regimen.
Aetna · Identified Aug 12, 2026Medium impact
Optical Coherence Tomography and Microelastography for Solid Tumors and Other Selected Indications (CPB 0886, reviewed 2026-03-03)
Aetna considers optical coherence tomography and microelastography experimental, investigational, or unproven for the listed intra-operative uses because their effectiveness has not been established. These uses include assessment of lymph nodes or tumor margins in breast conserving surgery, differentiation of pancreatic neoplastic lesions, differentiation of normal and diseased thyroid and parathyroid tissues, and solid tumor surgery including optical biopsy of lymph nodes and real-time determination of surgical margins. The policy lists CPT codes and ICD-10 codes as not covered for the indications it names.
Aetna · Identified Aug 12, 2026Medium impact
Cetuximab (Erbitux) (CPB 0684, reviewed 2025-12-03)
Aetna's commercial medical policy CPB 0684 covers cetuximab (Erbitux) for listed cancers when the member meets the criteria for that indication. Covered indications are colorectal cancer, head and neck cancer, non-small cell lung cancer, penile cancer and squamous cell skin cancer, each with its own conditions. Precertification is required. Aetna considers all other indications 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.
Blue Cross & Blue Shield of Mississippi · Identified Jun 20, 2026Medium impact
Intensity-Modulated Radiotherapy (IMRT): Cancer of the Head and Neck or Thyroid
A 09/15/2025 update changed the description of intensity modulators and radiotherapy treatment planning systems, and the policy statements were unchanged. Intensity-modulated radiotherapy may be considered medically necessary for head and neck cancers, which the policy defines as cancers of the oral cavity and lip, larynx, hypopharynx, oropharynx, nasopharynx, paranasal sinuses and nasal cavity, salivary glands, and occult primaries in the head and neck region. For thyroid cancer, it may be considered medically necessary when the cancer is in close proximity to organs at risk (esophagus, salivary glands, and spinal cord) and 3D conformal radiotherapy planning is not able to meet dose volume constraints for normal tissue tolerance. Intensity-modulated radiotherapy is investigational for thyroid cancers that do not meet these criteria.

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FREQUENTLY ASKED QUESTIONS

What insurance policy changes affect code C76.0?

There are 21 tracked policy changes affecting code C76.0, including updates from Aetna, Blue Cross & Blue Shield of Mississippi. Each change may modify coverage criteria, reimbursement rates, or prior-authorization requirements.

Which payers have updated policy for code C76.0?

Payers that have issued tracked updates for code C76.0 include: Aetna, Blue Cross & Blue Shield of Mississippi.

How do I get notified when code C76.0 policy changes?

Create a free account at PolicyChanges.app and save a search filtered to code C76.0. 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 C76.0?

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

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Nivolumab Products (Opdivo, Opdivo Qvantig, and Opdualag) (CPB 0892, reviewed 2026-10-28)

Intraoperative Radiation Therapy (IORT) (CPB 0721, reviewed 2026-10-15)

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

Docetaxel (CPB 0956, reviewed 2026-10-05)

Durvalumab (Imfinzi) (CPB 0917, reviewed 2026-09-25)

Intraoperative Radiation Therapy (IORT) (CPB 0721, reviewed 2025-10-20)

Irreversible Electroporation (NanoKnife) (CPB 0828, reviewed 2026-03-03)

Necitumumab (Portrazza) (CPB 0898, reviewed 2026-07-02)

Ramucirumab (Cyramza) (CPB 0883, reviewed 2026-06-03)

Cerebral Perfusion Studies (CPB 0663, reviewed 2026-04-14)

Carbogen Inhalation Therapy (CPB 0428, reviewed 2026-07-09)

Jaw Motion Rehabilitation Systems (CPB 0412, reviewed 2026-06-30)

Dental Services and Oral and Maxillofacial Surgery: Coverage Under Medical Plans (CPB 0082, reviewed 2026-03-18)

Dendritic Cell Immunotherapy (CPB 0377, reviewed 2026-05-26)

Docetaxel (CPB 0956, reviewed 2025-12-04)

Durvalumab (Imfinzi) (CPB 0917, reviewed 2026-06-25)

Paclitaxel, Albumin-Bound (CPB 0834, reviewed 2026-05-28)

Optical Coherence Tomography and Microelastography for Solid Tumors and Other Selected Indications (CPB 0886, reviewed 2026-03-03)

Cetuximab (Erbitux) (CPB 0684, reviewed 2025-12-03)

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

Intensity-Modulated Radiotherapy (IMRT): Cancer of the Head and Neck or Thyroid

What insurance policy changes affect code C76.0?

Which payers have updated policy for code C76.0?

How do I get notified when code C76.0 policy changes?

Why do payers change policies for code C76.0?