ICD-10 C83.89 is officially defined as "Other non-follicular lymphoma, extranodal and solid organ sites." code C83.89 is referenced in 13 tracked payer policy changes from Independence Blue Cross and Aetna. For billers and coders, staying current on payer-specific coverage criteria, reimbursement rules, and prior-authorization requirements for code C83.89 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 considers non-myeloablative hematopoietic cell transplantation (mini-allograft) medically necessary for members with acute lymphoblastic leukemia, acute myelogenous leukemia, aplastic anemia, chronic lymphocytic leukemia, chronic myelogenous leukemia, Hodgkin's disease, multiple myeloma, myelofibrosis, myelodysplasia, neuroblastoma, non-Hodgkin's lymphoma, sickle cell anemia or thalassemia major, where conventional allogeneic transplant is an established alternative. Aetna considers it experimental, investigational, or unproven for acquired angioedema, autoimmune diseases, breast cancer, essential thrombocythemia and polycythemia vera, melanoma, ovarian cancer, renal cancer and testicular cancer. For members with the listed diseases who are eligible for conventional ASCT, mini-allograft is a technical variation of an established procedure; for members who are ineligible for conventional ASCT, including those with other malignancies, mini-allograft is still considered 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 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 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 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.
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