ICD-10 C83.3A is officially defined as "Diffuse large B-cell lymphoma, in remission." code C83.3A is referenced in 24 tracked payer policy changes from Independence Blue Cross, Aetna, and 1 other payer. For billers and coders, staying current on payer-specific coverage criteria, reimbursement rules, and prior-authorization requirements for code C83.3A is critical to clean claim submission. Each entry below links to the full policy analysis with effective dates and action steps.
Independence Blue Cross Medicare Advantage policy MA08.108g expands coverage for Polivy (HCPCS J9309): it adds the GemOx-R regimen for Burkitt lymphoma, refines CAR T-cell sequencing criteria, and adds ICD-10 codes as medically necessary. The policy became effective November 2, 2026, so it is already in effect, and it covers Polivy under the Part B medical benefit only, not the Part D pharmacy benefit.
Independence Blue Cross Medicare Advantage policy MA08.139e adds Waldenstrom macroglobulinemia and lymphoplasmacytic lymphoma as a medically necessary use of Zynlonta (HCPCS J9359) for patients who have had a covalent BTK inhibitor or cannot take one, and adds a list of ICD-10 codes to that coverage. The policy became effective November 2, 2026, so it is already in effect, and it covers Zynlonta only under the Part B medical benefit, not the Part D pharmacy benefit.
Independence Blue Cross commercial policy 08.01.59g expands coverage for Polivy (HCPCS J9309): it adds the GemOx-R regimen for Burkitt lymphoma and refines CAR T-cell sequencing criteria, and it adds a long list of ICD-10 codes as medically necessary. The policy became effective November 2, 2026, so it is already in effect, and the notice's excerpt does not include the full criteria for the new mantle cell lymphoma heading.
Independence Blue Cross added Waldenstrom macroglobulinemia and lymphoplasmacytic lymphoma as a medically necessary use of Zynlonta (HCPCS J9359) for patients who have had a covalent BTK inhibitor or cannot take one, and it added a long list of ICD-10 codes to that coverage. The policy became effective November 2, 2026, so it is already in effect as of the analysis date, and it applies to IBX commercial plans.
Aetna's Clinical Policy Bulletin 1034 (reviewed 2026-10-16) establishes coverage criteria for epcoritamab-bysp (Epkinly), a bispecific antibody for treating relapsed or refractory B-cell lymphomas. The policy requires precertification for all Aetna participating providers and members, specifies approved treatment combinations and dosing schedules, and limits certain regimens to a maximum of 12 cycles. All other indications remain experimental/investigational.
Aetna's Clinical Policy Bulletin 0659 covers ibritumomab tiuxetan (Zevalin) for commercial medical plans. Aetna considers it medically necessary for relapsed or refractory, low-grade or follicular B-cell non-Hodgkin lymphoma, and for previously untreated follicular non-Hodgkin lymphoma in members who have achieved a partial or complete response to first-line chemotherapy. Aetna considers all other indications experimental, investigational or unproven, and considers a repeat course of treatment not medically necessary.
Aetna covers tisagenlecleucel (Kymriah) for commercial medical plans. Precertification of tisagenlecleucel is required of all Aetna participating providers and members in applicable plan designs. Covered indications are relapsed or refractory B-cell precursor acute lymphoblastic leukemia in members less than 26 years of age, relapsed or refractory B-cell lymphomas in members 18 years of age or older, relapsed or refractory ALK-positive large B-cell lymphoma if CD19-positive in members 18 years of age or older, and histologic (Richter) transformation to DLBCL in members 18 years of age or older when the stated criteria are met. Aetna considers tisagenlecleucel experimental, investigational or unproven for adults 26 years of age or older with acute lymphoblastic leukemia, acute myeloid leukemia, chronic lymphocytic leukemia, Hodgkin lymphoma, plasma cell disorders, primary central nervous system lymphoma, solid tumors and T-cell leukemia/lymphoma, and it considers repeat administration experimental and investigational.
Aetna's Clinical Policy Bulletin 0986 covers one dose of lisocabtagene maraleucel (Breyanzi) for commercial members 18 or older with specified B-cell lymphomas and chronic lymphocytic leukemia or small lymphocytic lymphoma, each under listed prior-treatment criteria, and for relapsed or refractory pediatric primary mediastinal large B-cell lymphoma after at least two chemoimmunotherapy regimens. Members with primary central nervous system lymphoma, a previous CD19-directed CAR T-cell therapy, an ECOG performance status of 3 or higher, or several listed active or unstable conditions are not eligible. Repeat administration and use for solid tumors are considered experimental, investigational, or unproven.
Aetna's Clinical Policy Bulletin 0994 covers loncastuximab tesirine-lpyl (Zynlonta) for commercial plans when treating large B-cell lymphoma, histologic transformation of indolent lymphomas to DLBCL, HIV-related B-cell lymphomas, and monomorphic post-transplant lymphoproliferative disorder (B-cell type), each under listed disease-status and prior-treatment criteria. Most of these criteria require two or more lines of systemic therapy and use as a single agent, and histologic transformation requires prior anthracycline-based treatment and a member who is not a transplant candidate. All other indications are considered experimental, investigational, or unproven.
Aetna covers glofitamab-gxbm (Columvi) for commercial medical plans when the member is pretreated with a single 1,000 mg dose of obinutuzumab (Gazyva) 7 days before the start of Columvi. Initial approval is listed for relapsed or refractory DLBCL, high grade B-cell lymphoma, mantle cell lymphoma, and other listed subtypes, each under the prior-therapy and combination conditions in the criteria, and for histologic (Richter) transformation to DLBCL. Continuation of therapy is covered for up to 12 cycles when there is no evidence of unacceptable toxicity or disease progression, and all other indications are considered experimental, investigational or unproven.
Aetna's criteria for polatuzumab vedotin-piiq (Polivy) apply to commercial medical plans, and Medicare criteria are in a separate Part B document. Precertification is required for all Aetna participating providers and members in applicable plan designs. Aetna considers Polivy medically necessary for up to 6 cycles for HIV-related B-cell lymphomas, diffuse large B-cell lymphoma, high-grade B-cell lymphomas, histologic transformation of indolent lymphomas, B-cell post-transplant lymphoproliferative disorders, mantle cell lymphoma and Burkitt lymphoma when the listed criteria are met. Continuation is considered medically necessary for up to 6 months (maximum of 6 cycles total) when there is no unacceptable toxicity or disease progression, and all other indications are considered experimental, investigational, or unproven.
Aetna considers brentuximab vedotin (Adcetris) medically necessary for commercial medical plans when the request meets one of the listed uses. Listed uses include classic Hodgkin lymphoma as a single agent or in named combinations, relapsed or refractory DLBCL, HGBL and histologic transformation of indolent lymphoma, pediatric primary mediastinal large B-cell lymphoma with nivolumab or pembrolizumab, several CD30-positive T-cell lymphomas and primary cutaneous lymphomas. Reauthorization is considered medically necessary for a listed indication when there is no evidence of unacceptable toxicity or disease progression, and all other indications are considered experimental, investigational, or unproven.
Aetna Clinical Policy Bulletin 0920 sets the commercial medical coverage criteria for tisagenlecleucel (Kymriah), a CD19-directed autologous CAR T-cell therapy. Aetna considers it medically necessary for relapsed or refractory B-cell precursor acute lymphoblastic leukemia in members under 26 years of age, for specified relapsed or refractory adult B-cell lymphomas (including DLBCL and follicular lymphoma) under stated criteria, for ALK-positive large B-cell lymphoma if CD19-positive, and for histologic (Richter) transformation to DLBCL under stated criteria. Aetna considers all other indications experimental, investigational, or unproven, including adult ALL, AML, CLL, Hodgkin lymphoma, plasma cell disorders, and repeat administration of the therapy.
Aetna Clinical Policy Bulletin 1057 sets the commercial medical coverage criteria for tislelizumab-jsgr (Tevimbra). Aetna considers it medically necessary for several cancers under indication-specific criteria, including subsequent treatment of metastatic anal carcinoma, esophageal and esophagogastric junction cancer, HER2-negative gastric adenocarcinoma, metastatic nasopharyngeal cancer, hepatocellular carcinoma, and histologic (Richter) transformation to diffuse large B-cell lymphoma. It also covers MSI-H, dMMR, or POLE/POLD1 ultra-hypermutated small bowel, colon, appendiceal, and rectal adenocarcinomas under the stated criteria, and considers all other indications experimental, investigational, or unproven.
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'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 considers tafasitamab-cxix (Monjuvi) medically necessary for commercial medical plans for relapsed or refractory follicular lymphoma when used with lenalidomide and rituximab for up to a maximum of 12 cycles. For other B-cell lymphomas, it is medically necessary in combination with lenalidomide for up to 12 cycles when the member has HIV-related B-cell lymphoma, histologic transformation of indolent lymphoma to DLBCL without eligibility for an autologous stem cell transplant, monomorphic post-transplant lymphoproliferative disorder (B-cell type), DLBCL, or high-grade B-cell lymphoma. Aetna considers all other indications experimental, investigational, or unproven.
Aetna considers mosunetuzumab-axgb (Lunsumio or Lunsumio Velo) medically necessary for follicular lymphoma when the disease had a partial response or no response to treatment or is relapsed or progressive, and the member has tried at least 2 prior lines of systemic therapy. It is also medically necessary for subsequent treatment of diffuse large B-cell lymphoma, high-grade B-cell lymphoma, HIV-related B-cell lymphomas and monomorphic post-transplant lymphoproliferative disorders (B-cell type) when the disease is relapsed or refractory and the drug will be used with polatuzumab vedotin (Lunsumio IV only). Continuation is medically necessary for up to 17 cycles total when there is no evidence of unacceptable toxicity or disease progression.
Aetna Clinical Policy Bulletin 0986 covers lisocabtagene maraleucel (Breyanzi) for commercial medical plans, and Medicare criteria are in a separate document. Aetna considers Breyanzi medically necessary as one dose for adult B-cell lymphomas after at least two lines of systemic therapy, or after first-line chemoimmunotherapy with relapsed or refractory disease in specified subtypes. It is also considered medically necessary for relapsed or refractory mantle cell lymphoma after a covalent Bruton tyrosine kinase inhibitor, relapsed or refractory ALK-positive large B-cell lymphoma if CD19-positive, relapsed or refractory CLL or SLL after a covalent Bruton tyrosine kinase inhibitor and BCL-2 inhibitor regimens, Richter transformation to DLBCL, and relapsed or refractory pediatric primary mediastinal large B-cell lymphoma under age 18. Members with primary central nervous system lymphoma, a previous treatment with Breyanzi or another CD19-directed CAR T-cell therapy, an ECOG performance status of 3 or greater, inadequate and unstable kidney, liver, pulmonary or cardiac function, active hepatitis B or C or other uncontrolled infection, active graft versus host disease, or an active inflammatory disorder are not eligible. Repeat administration and use for solid tumors are considered experimental, investigational, or unproven.
Aetna Clinical Policy Bulletin 0994 covers loncastuximab tesirine-lpyl (Zynlonta) for commercial medical plans, and Medicare criteria are in a separate document. For large B-cell lymphoma, including DLBCL NOS, DLBCL arising from low grade lymphoma, and high-grade B-cell lymphoma, Aetna considers it medically necessary when the member has partial response, no response, relapsed, progressive, or refractory disease, has received two or more prior lines of systemic therapy, and the drug is used as a single agent. For histologic transformation of indolent lymphomas to DLBCL, the member must have received an anthracycline-based regimen such as doxorubicin and must not be a candidate for transplant. For HIV-related B-cell lymphomas and monomorphic post-transplant lymphoproliferative disorder (B-cell type), the member must have received two or more lines of systemic therapy and the drug must be used as a single agent. Continuation is considered 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 considers glofitamab-gxbm (Columvi) medically necessary for commercial medical plans for B-cell lymphoma when the member is pretreated with a single dose of obinutuzumab (Gazyva) 7 days before starting glofitamab and one of the listed criteria is met. Those criteria cover subsequent therapy with GemOx for relapsed or refractory DLBCL, high grade B-cell lymphoma, HIV-related B-cell lymphoma or post-transplant lymphoproliferative disorder; a single agent after at least 2 prior lines of systemic therapy for partial response, no response, progressive, relapsed or refractory disease with specified subtypes including DLBCL, high grade B-cell lymphoma and mantle cell lymphoma; combination with polatuzumab vedotin-piiq for Burkitt lymphoma as a bridge to transplant. Aetna also considers glofitamab-gxbm medically necessary for histologic (Richter) transformation to DLBCL with the same obinutuzumab pretreatment. Aetna considers all other indications experimental, investigational, or unproven, and continuation of therapy up to a maximum of 12 cycles is considered medically necessary when there is no evidence of unacceptable toxicity or disease progression.
Aetna's clinical policy covers polatuzumab vedotin-piiq (Polivy) for commercial medical plans when the criteria for initial approval are met. Those criteria cover HIV-related B-cell lymphomas, diffuse large B-cell lymphoma, high-grade B-cell lymphomas, histologic transformation of indolent lymphomas, B-cell post-transplant lymphoproliferative disorders, mantle cell lymphoma and Burkitt lymphoma, with treatment approved for up to 6 cycles. Aetna considers Polivy experimental, investigational or unproven for all other indications.
Aetna Clinical Policy Bulletin 0899 covers elotuzumab (Empliciti) for commercial medical plans and requires precertification for all Aetna participating providers and members in applicable plan designs. Aetna considers elotuzumab medically necessary for previously treated multiple myeloma when it is used with lenalidomide and dexamethasone, with bortezomib and dexamethasone, or with pomalidomide and dexamethasone in members who have received at least two prior therapies, including an immunomodulatory agent and a proteasome inhibitor. The same combinations are considered medically necessary for POEMS syndrome, plasma cell-related monoclonal immunoglobulin deposition disease, and plasma cell-related monoclonal gammopathy of renal significance, and all other indications, including newly diagnosed multiple myeloma and smoldering multiple myeloma, are considered experimental, investigational, or unproven.
Epogen (epoetin alfa), Procrit (epoetin alfa), and Retacrit (epoetin alfa-epbx) are considered medically necessary for anemia related to zidovudine therapy in HIV-infected individuals, anemia in non-myeloid malignancies caused by concomitantly administered chemotherapy, anemia in individuals scheduled for elective, noncardiac, nonvascular surgery to reduce the need for allogeneic blood transfusions, and anemia associated with chronic kidney disease. Aranesp (darbepoetin alfa) is considered medically necessary for anemia associated with chronic kidney disease, including individuals on dialysis and not on dialysis, and for anemia in non-myeloid malignancies caused by concomitantly administered chemotherapy. The 09/09/2025 revision updated the indications descriptions and added that services related to delivery or administration of a medication determined to be not medically necessary are also considered not medically necessary.
Watch C83.3A
Get one email when a payer policy names C83.3A, a payer adds or drops it from a prior auth list, or Medicare changes its NCCI pairs, unit limit, payment or coverage articles.
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.