C96.9 Insurance Policy Changes

ICD-10 C96.9 is officially defined as "Malignant neoplasm of lymphoid, hematopoietic and related tissue, unspecified." code C96.9 is referenced in 17 tracked payer policy changes from Blue Cross Blue Shield of North Dakota, Blue Cross & Blue Shield of Mississippi, and 1 other payer. For billers and coders, staying current on payer-specific coverage criteria, reimbursement rules, and prior-authorization requirements for code C96.9 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 North Dakota · Identified Aug 29, 2026High impact
Pharmacy Policies Available Online
Blue Cross Blue Shield of North Dakota revised its Commercial prior authorization medical drug policies with changes effective October 13, 2026, including expanded indications for Casgevy, Keytruda, Opdivo and other products and updated criteria for many others. Effective September 1, 2026, Navitrux was added to the fosaprepitant policy and Cligavyx was added to the fulvestrant policy, each kept at full parity with its reference product, and the cerebral palsy spasticity exclusion was removed from the Xeomin pediatric upper limb indication. Several products also have HCPCS code changes effective January 1, 2027.
Blue Cross & Blue Shield of Mississippi · Effective Oct 1, 2026Medium impact
Vitamin D Testing
Serum measurement of vitamin D (25-hydroxyvitamin D [25(OH)D], CPT 82306) is considered medically necessary up to four times per calendar year for the following conditions, among others: biliary cirrhosis, celiac disease, hypercalcemia or hypocalcemia, hyperparathyroidism or hypoparathyroidism, intestinal malabsorption, liver cirrhosis, long-term use of anticonvulsants, glucocorticoids or other medications known to lower vitamin D levels, malnutrition, osteomalacia, osteoporosis, rickets, sarcoidosis, stage III-V chronic kidney disease and end stage renal disease, and vitamin D deficiency on replacement therapy to monitor treatment efficacy. Routine serum vitamin D testing performed for screening purposes in asymptomatic patients is considered not medically necessary. Intestinal failure-associated liver disease (ICD-10 K76.83) is listed as a new diagnosis code effective 10/01/2026.
Aetna · Identified Oct 23, 2026Medium impact
Omidubicel-onlv (Omisirge) (CPB 1032, reviewed 2026-10-16)
Aetna Clinical Policy Bulletin 1032 addresses omidubicel-onlv (Omisirge) for commercial medical plans. Aetna considers it medically necessary for one dose total in members 12 years of age and older with a hematologic malignancy who will receive umbilical cord blood transplantation with myeloablative conditioning, and for one dose total in members 6 years of age and older with severe aplastic anemia (SAA) following reduced intensity conditioning. Aetna considers all other indications experimental, investigational, or unproven.
Aetna · Identified Oct 10, 2026Medium impact
Repository Corticotropin Injection (Acthar Gel and Purified Cortrophin Gel) (CPB 0762, reviewed 2026-10-08)
Aetna considers repository corticotropin injection (Acthar Gel only) medically necessary for infantile spasms in members less than 2 years of age, and considers all other indications experimental, investigational, unproven, or not medically necessary. Precertification of Acthar Gel or Purified Cortrophin Gel is required of all Aetna participating providers and members in applicable plan designs. Purified Cortrophin Gel is considered experimental, investigational, or unproven for infantile spasms because it is not FDA-approved, nor has a compendial use, for this indication, and use of Acthar Gel in combination with Purified Cortrophin Gel is considered experimental, investigational, or unproven.
Aetna · Identified Sep 29, 2026Medium impact
Cancer Vaccines (CPB 0557, reviewed 2026-08-27)
Aetna considers several cancer vaccines experimental, investigational, or unproven because their safety and effectiveness have not been established. These include the helper multi-peptide (6MHP) vaccine for metastatic melanoma, the melanoma vaccine (also known as Theraccine or Oncophage) for any indication, HLA-A24-binding peptide vaccines for gastric cancer, the p16(INK4a)-based peptide vaccine for HPV-associated cancers, the p62 DNA vaccine (Elenagen) for solid tumors, and whole cancer stem cell-based vaccines used as an adjuvant strategy for the surgical management of solid tumors. Aetna also states that the clinical evidence is not sufficient to permit conclusions on health outcomes for tumor-associated antigenic peptide-based vaccine therapy in listed cancers, including breast, colorectal, lung, ovarian and pancreatic cancer.
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 19, 2026Medium impact
Zoledronic Acid (CPB 0524, reviewed 2026-02-12)
Aetna's clinical policy bulletin covers zoledronic acid for commercial medical plans. Zoledronic acid 5 mg (Reclast or generic) is considered medically necessary for postmenopausal osteoporosis, osteoporosis in men, glucocorticoid-induced osteoporosis, Paget's disease of bone, and treatment-related bone loss in men with prostate cancer receiving androgen deprivation therapy, when the listed criteria are met. Zoledronic acid 4 mg (formerly branded Zometa) is considered medically necessary for bone metastases from a solid tumor, certain breast cancer indications, hypercalcemia of malignancy, Langerhans cell histiocytosis with bone disease, multiple myeloma, and systemic mastocytosis with osteopenia or osteoporosis. Aetna considers all other indications experimental, investigational, or unproven.
Aetna · Identified Aug 18, 2026Medium impact
Hospitalization for the Initiation of Ketogenic Diet (CPB 0226, reviewed 2026-04-23)
Aetna considers hospitalization for initiation of a ketogenic diet medically necessary for intractable seizures, including Doose syndrome and Lennox-Gastaut syndrome, when all listed selection criteria are met, and for persons with glucose transporter protein type 1 deficiency or pyruvate dehydrogenase complex deficiency. Aetna considers hospitalization for initiation of a ketogenic diet of unproven value for all other indications, including adult super-refractory status epilepticus, Alzheimer's disease, autism spectrum disorder, cancer, migraine prevention, multiple sclerosis, Parkinson's disease, schizophrenia and type 2 diabetes. Hospitalization for initiation of the Atkins diet for intractable seizures, mitochondrial diseases, or other indications is considered experimental, investigational, or unproven.
Aetna · Identified Aug 17, 2026Medium impact
Hematopoietic Cell Transplantation for Non-Hodgkin's Lymphoma (CPB 0494, reviewed 2026-08-03)
Aetna Clinical Policy Bulletin 0494 covers hematopoietic cell transplantation for non-Hodgkin's lymphoma (NHL). Aetna considers autologous transplant medically necessary for relapsed or primary refractory NHL when the transplanting institution's protocol criteria are met, or, without a protocol, when the person has relapsed or refractory NHL with evidence of chemotherapy-responsive disease. Aetna considers allogeneic transplant medically necessary for relapsed NHL (including relapse after autologous transplant) or primary refractory NHL when a suitable HLA-matched or haploidentical donor or matched cord blood is available and there is no serious organ dysfunction, and considers tandem autologous and autologous-allogeneic transplants experimental, investigational, or unproven for NHL.
Aetna · Identified Aug 17, 2026Medium impact
Strontium Chloride Sr-89 (CPB 0361, reviewed 2026-01-09)
Aetna considers strontium chloride Sr-89 medically necessary for the relief of bone pain when the member has a cancer diagnosis and bone metastases. Aetna considers all other indications experimental, investigational, or unproven, including use in members with cancer not involving the bone. Continued therapy on reauthorization is medically necessary when there is no evidence of unacceptable toxicity on the current regimen and the member is experiencing clinical benefit.
Aetna · Identified Aug 17, 2026Medium impact
Stereotactic Radiosurgery (CPB 0083, reviewed 2026-03-11)
Aetna considers stereotactic radiosurgery (SRS) medically necessary in certain circumstances, and refers to the eviCore Healthcare Radiation Therapy Clinical Guidelines for medical necessity criteria. Cranial SRS is medically necessary for benign brain and spinal tumors, cranial arteriovenous malformations, cavernous malformations and hemangiomas, trigeminal neuralgia that has not responded to more conservative treatments, severe essential tremor not adequately responsive to standard medical therapy, disabling tremor in Parkinson's disease for patients who meet thalamotomy criteria but are not surgical candidates, and primary brain tumors and primary or secondary tumors involving the spine. For brain metastases, SRS is considered appropriate with a Karnofsky Performance Status of 40 or greater (or expected to return to 70 or greater), or an ECOG status of 3 or less (or expected to return to 2 or less), fewer than 10 metastatic lesions, and control of or expected control of extracranial disease. Stereotactic body radiation therapy is medically necessary for liver or hepatobiliary cancer stage I to II, organ-confined prostate cancer, inoperable stage I or IIA lung cancer, unresectable stage I to III pancreatic cancer, recurrent disease requiring re-irradiation, and oligometastatic breast, non-small cell lung, colorectal, renal cell, prostate, sarcoma, melanoma and head and neck cancers with 1 to 5 total metastases, and Aetna considers SRS experimental, investigational, or unproven for cluster headaches, epilepsy (except when associated with treatment of arteriovenous malformations or brain tumors), and mammographic microcalcification.
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
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
Cancer Vaccines (CPB 0557, reviewed 2025-12-02)
Cancer vaccines are considered experimental, investigational, or unproven because their safety and effectiveness have not been established. The listed items are the helper multi-peptide (6MHP) vaccine for metastatic melanoma, HLA-A24-binding peptide vaccines for gastric cancer, the melanoma vaccine (also known as Theraccine or Oncophage) for any indication, the p16(INK4a)-based peptide vaccine for human papillomavirus-associated cancers, the p62 DNA vaccine (Elenagen) for solid tumors, and whole cancer stem cell-based vaccines used as an adjuvant strategy for the surgical management of solid tumors. The clinical evidence is stated as not sufficient to permit conclusions on health outcome effects of tumor-associated antigenic peptide-based vaccine therapy for acute myeloid leukemia, breast cancer, central nervous system cancers, colorectal cancer, gallbladder cancer, gastric cancer, glioma, head and neck cancer, hepatic cancer, lung cancer, oral squamous cell carcinoma, ovarian cancer and pancreatic cancer.
Aetna · Identified Aug 12, 2026Medium impact
Omidubicel-onlv (Omisirge) (CPB 1032, reviewed 2026-04-27)
Aetna's clinical policy bulletin for omidubicel-onlv (Omisirge) applies to commercial medical plans and states that precertification is required of all Aetna participating providers and members in applicable plan designs. Aetna considers omidubicel-onlv medically necessary for one dose total in members 12 years of age and older with a hematologic malignancy who will receive umbilical cord blood transplantation, when the requested medication will be used to reduce the time to neutrophil recovery and incidence of infection and the member will receive myeloablative conditioning therapy. It is also considered medically necessary for one dose total in members 6 years of age and older with severe aplastic anemia (SAA) following reduced intensity conditioning therapy, and Aetna considers all other indications experimental, investigational, or unproven.
Aetna · Identified Aug 12, 2026Medium impact
Cabazitaxel (Jevtana) (CPB 0806, reviewed 2026-03-12)
Aetna considers cabazitaxel (Jevtana) medically necessary for metastatic castration-resistant prostate cancer when the member was previously treated with a docetaxel-containing regimen or is not a candidate for or is intolerant to docetaxel, or when the member was previously treated with novel hormone therapy such as enzalutamide or abiraterone. Aetna also considers it medically necessary for metastatic castration-resistant small cell or neuroendocrine prostate cancer, and treatment continues when there is no evidence of unacceptable toxicity or disease progression on the current regimen. Aetna considers cabazitaxel not medically necessary for members with neutrophils of 1,500 cells/mm3 or less or severe hepatic impairment (total bilirubin greater than 3 x ULN), and considers all other indications experimental, investigational or unproven.
Blue Cross & Blue Shield of Mississippi · Identified Jun 20, 2026Medium impact
Hematopoietic Cell Transplantation for Solid Tumors of Childhood
Autologous hematopoietic cell transplantation may be considered medically necessary at initial treatment of high-risk neuroblastoma and high-risk Ewing sarcoma, for recurrent or refractory neuroblastoma and Ewing sarcoma, and for metastatic retinoblastoma. Tandem autologous transplant may be considered medically necessary for high-risk neuroblastoma. Autologous transplant is considered investigational as initial treatment of low- or intermediate-risk neuroblastoma and Ewing sarcoma and for rhabdomyosarcoma, Wilms tumor, osteosarcoma and retinoblastoma without metastasis, and allogeneic transplant for pediatric solid tumors and salvage allogeneic transplant after relapse or failure of response to autologous transplant are considered investigational.

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FREQUENTLY ASKED QUESTIONS

What insurance policy changes affect code C96.9?

There are 17 tracked policy changes affecting code C96.9, including updates from Blue Cross Blue Shield of North Dakota, Blue Cross & Blue Shield of Mississippi, Aetna. Each change may modify coverage criteria, reimbursement rates, or prior-authorization requirements.

Which payers have updated policy for code C96.9?

Payers that have issued tracked updates for code C96.9 include: Blue Cross Blue Shield of North Dakota, Blue Cross & Blue Shield of Mississippi, Aetna.

How do I get notified when code C96.9 policy changes?

Create a free account at PolicyChanges.app and save a search filtered to code C96.9. 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 C96.9?

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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Pharmacy Policies Available Online

Vitamin D Testing

Omidubicel-onlv (Omisirge) (CPB 1032, reviewed 2026-10-16)

Repository Corticotropin Injection (Acthar Gel and Purified Cortrophin Gel) (CPB 0762, reviewed 2026-10-08)

Cancer Vaccines (CPB 0557, reviewed 2026-08-27)

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

Zoledronic Acid (CPB 0524, reviewed 2026-02-12)

Hospitalization for the Initiation of Ketogenic Diet (CPB 0226, reviewed 2026-04-23)

Hematopoietic Cell Transplantation for Non-Hodgkin's Lymphoma (CPB 0494, reviewed 2026-08-03)

Strontium Chloride Sr-89 (CPB 0361, reviewed 2026-01-09)

Stereotactic Radiosurgery (CPB 0083, reviewed 2026-03-11)

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

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

Cancer Vaccines (CPB 0557, reviewed 2025-12-02)

Omidubicel-onlv (Omisirge) (CPB 1032, reviewed 2026-04-27)

Cabazitaxel (Jevtana) (CPB 0806, reviewed 2026-03-12)

Hematopoietic Cell Transplantation for Solid Tumors of Childhood

What insurance policy changes affect code C96.9?

Which payers have updated policy for code C96.9?

How do I get notified when code C96.9 policy changes?

Why do payers change policies for code C96.9?