C91.12 Insurance Policy Changes

ICD-10 C91.12 is officially defined as "Chronic lymphocytic leukemia of B-cell type in relapse." code C91.12 is referenced in 16 tracked payer policy changes from Blue Cross & Blue Shield of Mississippi, Blue Cross Blue Shield of North Dakota, and 2 other payers. For billers and coders, staying current on payer-specific coverage criteria, reimbursement rules, and prior-authorization requirements for code C91.12 is critical to clean claim submission. Each entry below links to the full policy analysis with effective dates and action steps.

Blue Cross & Blue Shield of Mississippi · Effective Oct 1, 2026Medium impact
Next-Generation Sequencing for the Assessment of Measurable Residual Disease
Next-generation sequencing (NGS) to detect measurable residual disease (MRD), such as clonoSEQ, may be considered medically necessary as an alternative test at a threshold of 10-4 for acute lymphoblastic leukemia and chronic lymphocytic leukemia, and at a threshold of 10-5 for multiple myeloma. NGS for MRD at thresholds below those levels is investigational, and it is investigational for diffuse large B-cell lymphoma, mantle cell lymphoma and all other situations. Already effective 10/01/2026, CPT code 0688U, NGS of circulating tumor DNA for MRD in colorectal cancer, was added as an investigational code.
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.
Excellus BlueCross BlueShield · Effective Feb 19, 2026Medium impact
Allogeneic Hematopoietic Stem Cell Transplantation (Allo-HSCT) 7.02.02
Excellus medical policy 7.02.02 sets when allogeneic hematopoietic stem cell transplantation (allo-HSCT) is considered medically appropriate. It applies when the candidate meets the transplanting institution's selection criteria, the multidisciplinary team evaluates the individual and recommends treatment, and the individual is treated for one of the listed indications. The listed indications include acute and chronic leukemias, non-Hodgkin lymphoma, myelodysplastic diseases at intermediate or high risk, sickle cell anemia under stated criteria, transfusion-dependent thalassemia, bone marrow failure syndromes, severe combined immunodeficiency, hemophagocytic disorders, several storage and leukodystrophy disorders, and certain skeletal and metabolic bone disorders. Allo-HSCT is considered investigational for all other indications. The February 19, 2026 revision simplified the criteria to the indication level, removed the investigational indications list and added HCPCS code S2142.
Blue Cross Blue Shield of North Dakota · Effective Feb 10, 2026Medium impact
Pharmacy Policy Updates
Commercial prior authorization medical drug policies have revisions effective Feb. 10, 2026, including new indications such as Epkinly in combination with rituximab and lenalidomide for relapsed or refractory follicular lymphoma, Gazyva for active lupus nephritis, Darzalex SQ for high-risk smoldering multiple myeloma, and Bevacizumab for respiratory papillomatosis. Commercial post service claim edit policies for Botox, Dysport, Daxxify, Myobloc, Xeomin, Asparlas, and Besponsa have revisions effective Jan. 1, 2026, with multiple sclerosis coverage moving from G35 to G35.A through G35.D. Vyepti now covers chronic migraine with ICD-10 codes G43.E01, G43.E09, G43.E11, and G43.E19, and the Infugem policy is being retired because the manufacturer discontinued the product.
Aetna · Identified Oct 18, 2026Medium impact
Ibritumomab Tiuxetan (Zevalin) (CPB 0659, reviewed 2026-10-15)
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 · Identified Oct 15, 2026Medium impact
Axicabtagene Ciloleucel (Yescarta) (CPB 0924, reviewed 2026-10-09)
This bulletin covers Yescarta (axicabtagene ciloleucel) for commercial medical plans, and Yescarta requires precertification through National Medical Excellence (NME) at 1-877-212-8811. Aetna considers one dose medically necessary for the B-cell lymphoma indications listed in the policy, including the large B-cell lymphoma subtypes listed, follicular lymphoma after two or more lines of systemic therapy, histologic (Richter) transformation to DLBCL, relapsed or refractory pediatric primary mediastinal large B-cell lymphoma, and relapsed or refractory primary central nervous system lymphoma. Aetna considers acute lymphoblastic leukemia, indolent non-Hodgkin lymphomas other than the subtypes listed, mantle cell lymphoma, solid tumors and repeat administration experimental, investigational, or unproven, and members with a previous CD19-directed CAR T-cell therapy or an ECOG performance status of 3 or greater are not eligible.
Aetna · Identified Oct 4, 2026Medium impact
Hematopoietic Cell Transplantation for Selected Leukemias (CPB 0640, reviewed 2026-09-11)
Aetna's clinical policy bulletin CPB 0640 (reviewed 2026-09-11, first detected here 2026-10-04, so this is historical material) sets when stem cell transplant is covered for acute lymphocytic, myeloid and other leukemias. It covers allogeneic transplants for most of these leukemias when the transplant center's criteria are met, but it lists autologous transplant for ALL, CMML and JMML, tandem transplants for ALL, repeat transplants for AML that has not gone into remission, hepcidin testing and micro-transplantation as experimental. The notice gives no new effective date and does not say what changed in this review, so confirm the current bulletin with Aetna before acting on it.
Aetna · Identified Oct 3, 2026Medium impact
Lisocabtagene Maraleucel (Breyanzi) (CPB 0986, reviewed 2026-09-14)
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 · Identified Sep 29, 2026Medium impact
Brentuximab Vedotin (Adcetris) (CPB 0823, reviewed 2026-09-24)
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 · Identified Sep 29, 2026Medium impact
Bendamustine Products (CPB 0875, reviewed 2026-09-15)
Aetna's Clinical Policy Bulletin 0875 covers bendamustine products (Belrapzo, Bendeka, Treanda, Vivimusta and generic bendamustine) for commercial medical plans, and precertification is required for these products in applicable plan designs. Aetna considers bendamustine medically necessary for the listed indications when the stated criteria are met, including chronic lymphocytic leukemia/small lymphocytic leukemia, several B-cell and T-cell lymphomas, multiple myeloma, classic Hodgkin lymphoma, Waldenstrom macroglobulinemia, systemic light chain amyloidosis, autologous transplant conditioning and cold agglutinin disease. Aetna considers all other indications experimental, investigational, or unproven, including breast cancer, colorectal cancer, melanoma and non-small cell lung cancer.
Aetna · Identified Aug 18, 2026Medium impact
Tisagenlecleucel (Kymriah) (CPB 0920, reviewed 2026-02-24)
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 · 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 16, 2026Medium impact
Lisocabtagene Maraleucel (Breyanzi) (CPB 0986, reviewed 2026-03-11)
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 · Identified Aug 13, 2026Medium impact
Plerixafor (CPB 0779, reviewed 2026-02-13)
Aetna's policy covers plerixafor (Mozobil or generic plerixafor) for hematopoietic stem cell mobilization when it is given after a granulocyte-colony stimulating factor such as filgrastim, after chemo-mobilization, or as part of a gene therapy protocol, and when it is not used beyond 4 consecutive days or after stem cell harvest or apheresis is complete. Continuation of therapy is considered medically necessary for members who meet the initial selection criteria. Aetna considers plerixafor experimental, investigational or unproven for all other indications, including the conditions listed in the policy such as acute leukemias, sickle cell disease, WHIM syndrome and neutropenia treatment.
Aetna · Identified Aug 12, 2026Medium impact
Bendamustine Products (CPB 0875, reviewed 2026-02-24)
Precertification of bendamustine (Belrapzo, Bendeka, Treanda, Vivimusta, and generic bendamustine) is required of all Aetna participating providers and members in applicable commercial plan designs. Aetna considers bendamustine medically necessary for CLL or SLL without chromosome 17p deletion or TP53 mutation, and for listed B-cell lymphomas, T-cell lymphomas, multiple myeloma, POEMS syndrome, plasma cell-related MIDD and MGRS, classic Hodgkin lymphoma, nodular lymphocyte predominant Hodgkin lymphoma, Waldenstrom macroglobulinemia, systemic light chain amyloidosis, autologous transplant conditioning, and cold agglutinin disease when the listed criteria are met. 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 on the current regimen.
Aetna · Identified Aug 12, 2026Low impact
Ofatumumab (Arzerra) (CPB 0794, reviewed 2025-10-24)
This is historical material: Aetna Clinical Policy Bulletin 0794, Ofatumumab (Arzerra), was reviewed 2025-10-24. The bulletin states Aetna considers ofatumumab medically necessary for chronic lymphocytic leukemia (CLL) or small lymphocytic lymphoma (SLL) and experimental, investigational or unproven for all other listed indications. The source text does not state an effective date or describe what changed.

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FREQUENTLY ASKED QUESTIONS

What insurance policy changes affect code C91.12?

There are 16 tracked policy changes affecting code C91.12, including updates from Blue Cross & Blue Shield of Mississippi, Blue Cross Blue Shield of North Dakota, Excellus BlueCross BlueShield. Each change may modify coverage criteria, reimbursement rates, or prior-authorization requirements.

Which payers have updated policy for code C91.12?

Payers that have issued tracked updates for code C91.12 include: Blue Cross & Blue Shield of Mississippi, Blue Cross Blue Shield of North Dakota, Excellus BlueCross BlueShield, Aetna.

How do I get notified when code C91.12 policy changes?

Create a free account at PolicyChanges.app and save a search filtered to code C91.12. 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 C91.12?

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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Next-Generation Sequencing for the Assessment of Measurable Residual Disease

Pharmacy Policies Available Online

Allogeneic Hematopoietic Stem Cell Transplantation (Allo-HSCT) 7.02.02

Pharmacy Policy Updates

Ibritumomab Tiuxetan (Zevalin) (CPB 0659, reviewed 2026-10-15)

Axicabtagene Ciloleucel (Yescarta) (CPB 0924, reviewed 2026-10-09)

Hematopoietic Cell Transplantation for Selected Leukemias (CPB 0640, reviewed 2026-09-11)

Lisocabtagene Maraleucel (Breyanzi) (CPB 0986, reviewed 2026-09-14)

Brentuximab Vedotin (Adcetris) (CPB 0823, reviewed 2026-09-24)

Bendamustine Products (CPB 0875, reviewed 2026-09-15)

Tisagenlecleucel (Kymriah) (CPB 0920, reviewed 2026-02-24)

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

Lisocabtagene Maraleucel (Breyanzi) (CPB 0986, reviewed 2026-03-11)

Plerixafor (CPB 0779, reviewed 2026-02-13)

Bendamustine Products (CPB 0875, reviewed 2026-02-24)

Ofatumumab (Arzerra) (CPB 0794, reviewed 2025-10-24)

What insurance policy changes affect code C91.12?

Which payers have updated policy for code C91.12?

How do I get notified when code C91.12 policy changes?

Why do payers change policies for code C91.12?