What insurance policy changes affect HCPCS J9173?

There are 17 tracked policy changes affecting HCPCS J9173, including updates from Humana, BCBS Tennessee, Independence Blue Cross. Each change may modify coverage criteria, reimbursement rates, or prior-authorization requirements.

Which payers have updated policy for HCPCS J9173?

Payers that have issued tracked updates for HCPCS J9173 include: Humana, BCBS Tennessee, Independence Blue Cross, Aetna.

How do I get notified when HCPCS J9173 policy changes?

Create a free account at PolicyChanges.app and save a search filtered to HCPCS J9173. You will receive a daily digest email whenever a new policy change references this code.

Why do payers change policies for HCPCS J9173?

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.

J9173 Insurance Policy Changes

HCPCS J9173 is officially defined as "Injection, durvalumab, 10 mg." HCPCS J9173 is referenced in 17 tracked payer policy changes from Humana, BCBS Tennessee, and 2 other payers. For billers and coders, staying current on payer-specific coverage criteria, reimbursement rules, and prior-authorization requirements for HCPCS J9173 is critical to clean claim submission. Each entry below links to the full policy analysis with effective dates and action steps.

High impact
Imfinzi (durvalumab)
Humana·Effective Oct 1, 2026
Humana Indiana Medicaid has established a prior authorization policy for Imfinzi (durvalumab) covering nine cancer indications including biliary tract cancer, endometrial cancer, gastric/gastroesophageal junction adenocarcinoma, hepatocellular carcinoma, non-small cell lung cancer (metastatic, perioperative, and unresectable), small cell lung cancer (extensive and limited stage), and bladder cancer. The policy specifies coverage criteria, treatment combinations, exclusions (including prior anti-PD-1/PD-L1 therapy), and approval durations of 6 months per initial or renewal authorization.
High impact
Imfinzi (durvalumab) (New)
Humana·Effective Oct 1, 2026
Humana Medicaid Indiana has released a new pharmacy coverage policy for Imfinzi (durvalumab), effective October 1, 2026. The policy establishes prior authorization requirements for 9 cancer indications with specific clinical criteria and contraindications based on prior anti-PD-1/PD-L1 therapy exposure. Billing teams must implement prior authorization workflows for all Imfinzi claims and verify member eligibility against documented diagnosis, treatment regimen, and exclusion criteria.
High impact
Imfinzi (durvalumab) (New)
Humana·Effective Oct 1, 2026
Humana Medicaid (Louisiana) has implemented a new prior authorization policy for Imfinzi (durvalumab) effective October 1, 2026, covering 10 oncologic indications including biliary tract cancer, endometrial cancer, gastric/GE junction adenocarcinoma, hepatocellular carcinoma, non-small cell lung cancer (metastatic, perioperative, unresectable), small cell lung cancer (extensive and limited stage), and bladder cancer. The policy requires specific combination chemotherapy regimens and excludes patients with prior disease progression on anti-PD-1/PD-L1 therapies.
High impact
Imfinzi (durvalumab) (New)
Humana·Effective Oct 1, 2026
Humana Medicaid Ohio has issued a new prior authorization policy for Imfinzi (durvalumab) covering 10 cancer indications, effective October 1, 2026. The policy requires prior authorization for all covered uses and establishes specific clinical criteria, drug combination requirements, and exclusions (including prior anti-PD-1/PD-L1 therapy failure) for each indication. Billing teams must implement prior authorization workflows immediately upon the effective date.
High impact
Atezolizumab and Hyaluronidase-tqjs (Tecentriq Hybreza™)
BCBS Tennessee·Effective Sep 30, 2026
This is a NEW medical policy for Tecentriq Hybreza™ (atezolizumab and hyaluronidase-tqjs), an immunotherapy drug covering multiple cancer indications including NSCLC, SCLC, HCC, melanoma, and others. The policy establishes prior authorization requirements, coverage criteria, and required documentation (including PD-L1 expression testing, genetic mutation testing, and tumor profiling). All authorizations are limited to 6-month intervals. DO NOT implement until September 30, 2026.
High impact
08.01.65f, Durvalumab (Imfinzi®) and Tremelimumab-actl (Imjudo®)
Independence Blue Cross·Effective Aug 24, 2026
Independence Blue Cross updated policy 08.01.65f to expand coverage for durvalumab (Imfinzi) and tremelimumab-actl (Imjudo) to include Small Bowel Adenocarcinoma as a new medically necessary indication, and revised coverage criteria for six existing cancer types (Ampullary Adenocarcinoma, Esophageal/Esophagogastric, Gastric, Non-Small Cell Lung, Small Cell Lung, and Uterine Neoplasms) in accordance with NCCN guidelines. The policy also adds new duration of treatment requirements for durvalumab documented in Attachment A.
High impact
Durvalumab (Imfinzi) (CPB 0917, reviewed 2026-06-25)
Aetna·Effective Jun 25, 2026
Aetna has updated its coverage policy for durvalumab (Imfinzi) effective June 25, 2026, establishing specific clinical criteria for approval across 12 cancer indications including NSCLC, SCLC, biliary tract, cervical, colorectal, and other solid tumors. The policy requires precertification for all durvalumab treatment and establishes continuation/reauthorization criteria with defined treatment duration limits. Billing teams must implement prior authorization workflows and ensure claims include genetic/molecular testing documentation as specified in the criteria.
High impact
Imfinzi (durvalumab)
Humana·Effective May 1, 2026
Humana Indiana Medicaid establishes a new prior authorization policy for Imfinzi (durvalumab) covering nine cancer indications effective May 1, 2026. The policy requires prior auth approval for specific diagnoses and treatment combinations, with defined criteria and exclusions (including prior anti-PD-1/PD-L1 therapy progression). Billing teams must implement prior auth requirements in their systems and ensure claims meet all specified criteria before submission.
High impact
Imfinzi (durvalumab)
Humana·Effective May 1, 2026
Humana Louisiana Medicaid has established a new prior authorization policy for Imfinzi (durvalumab) effective May 1, 2026, covering nine cancer indications. The policy requires prior authorization for all uses, with specific clinical criteria and exclusions for each indication (e.g., disease progression on prior anti-PD-1/PD-L1 therapy). Billing and clinical teams must verify member eligibility, confirm diagnosis matches policy criteria, and submit prior authorization requests before dispensing.
High impact
Imfinzi (durvalumab)
Humana·Effective May 1, 2026
Humana Medicaid (Ohio) has implemented a new Prior Authorization policy for Imfinzi (durvalumab) effective May 1, 2026, covering 9 oncology indications including biliary tract cancer, endometrial cancer, gastric/GE junction adenocarcinoma, hepatocellular carcinoma, and various lung cancers. The policy requires specific diagnostic criteria, combination therapy regimens, and disease progression exclusions for each indication. All approvals are limited to initial 6-month periods with 6-month renewals.
High impact
Tislelizumab-jsgr (Tevimbra) (CPB 1057, reviewed 2025-12-05)
Aetna·Effective Dec 5, 2025
Aetna has issued a new Clinical Policy Bulletin (CPB 1057) effective 2025-12-05 establishing coverage criteria for tislelizumab-jsgr (Tevimbra), a PD-1 inhibitor immunotherapy. The policy covers nine cancer indications (anal, esophageal, gastric, head/neck, hepatocellular, small bowel, colon, appendiceal, and rectal cancers plus histologic Richter transformation) with specific eligibility requirements. All Aetna commercial members require precertification before treatment, and members with prior PD-1/PD-L1 inhibitor progression are excluded from coverage.
High impact
Fundus Photography (CPB 0539, reviewed 2025-08-21)
Aetna·Effective Aug 21, 2025
Aetna's Fundus Photography policy (CPB 0539) establishes medical necessity criteria for fundus photography (CPT 92250), limiting coverage to two times per year with specific clinical indications. The policy explicitly excludes automated color fundus photography for AMD screening and computer-aided analysis (CPT 0380T), and denies baseline fundus photography before MEK inhibitor therapy initiation. A comprehensive list of experimental/unproven indications is now non-covered.
High impact
08.01.65e, Durvalumab (Imfinzi®) and Tremelimumab-actl (Imjudo®)
Independence Blue Cross·Effective Jul 28, 2025
Independence Blue Cross updated policy 08.01.65e to version 08.01.65f, effective July 28, 2025. New medically necessary indications were added for bladder cancer and uterine neoplasms, and medical necessity criteria were revised for five cancer types (ampullary adenocarcinoma, biliary tract cancers, hepatocellular carcinoma, non-small cell lung cancer, and small cell lung cancer) based on updated NCCN guidelines. All ICD-10 diagnosis codes were removed from the policy document as informational only.
Medium impact
Imfinzi (durvalumab)
Humana·Effective Oct 1, 2026
Humana Medicaid in Ohio updated its prior authorization policy for Imfinzi (durvalumab) effective October 1, 2026, establishing coverage criteria and exclusions across nine cancer indications including biliary tract, endometrial, gastric, hepatocellular, lung, and bladder cancers. The policy specifies required combination therapies, disease staging requirements, and treatment duration limits for each indication, with standard 6-month initial and renewal approval periods subject to clinical review.
Medium impact
MA08.123f, Durvalumab (Imfinzi®) and Tremelimumab-actl (Imjudo®)
Independence Blue Cross·Effective Aug 24, 2026
Independence Blue Cross updated MA08.123f to expand durvalumab (Imfinzi) and tremelimumab-actl (Imjudo) coverage criteria effective 08/24/2026. Small Bowel Adenocarcinoma was added as a new medically necessary indication, and coverage criteria were revised for six existing cancer types (Ampullary Adenocarcinoma, Esophageal/Esophagogastric, Gastric, Non-Small Cell Lung, Small Cell Lung, and Uterine Neoplasms). Treatment duration requirements for durvalumab were also formalized in Attachment A.
Medium impact
MA08.173a, Tislelizumab-jsgr (Tevimbra®)
Independence Blue Cross·Effective Jun 1, 2026
MA08.173a updates medical necessity criteria for Tislelizumab-jsgr (Tevimbra®), a PD-1 inhibitor immunotherapy. This policy change affects prior authorization and coverage requirements for this pharmaceutical agent under Medicare Advantage plans effective June 1, 2026.
Medium impact
MA08.123e, Durvalumab (Imfinzi®) and Tremelimumab-actl (Imjudo®)
Independence Blue Cross·Effective Jul 28, 2025
Independence Blue Cross updated MA policy MA08.123e to MA08.123f, effective July 28, 2025, adding coverage for durvalumab (Imfinzi) and tremelimumab-actl (Imjudo) in two new cancer indications (Bladder Cancer and Uterine Neoplasms) and revising coverage criteria for five existing cancer types based on updated NCCN guidelines. ICD-10 diagnosis codes have been removed from the policy as informational only, requiring providers to report the most appropriate diagnosis code supporting medical necessity.

All billing codes J3590 C9399 J3490 99213 99214 99212

Get alerts for changes like this

Save a search and receive a daily digest whenever a new policy change matches your filters.

Create a free alert

Imfinzi (durvalumab)

Imfinzi (durvalumab) (New)

Imfinzi (durvalumab) (New)

Imfinzi (durvalumab) (New)

Atezolizumab and Hyaluronidase-tqjs (Tecentriq Hybreza™)

08.01.65f, Durvalumab (Imfinzi®) and Tremelimumab-actl (Imjudo®)

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

Imfinzi (durvalumab)

Imfinzi (durvalumab)

Imfinzi (durvalumab)

Tislelizumab-jsgr (Tevimbra) (CPB 1057, reviewed 2025-12-05)

Fundus Photography (CPB 0539, reviewed 2025-08-21)

08.01.65e, Durvalumab (Imfinzi®) and Tremelimumab-actl (Imjudo®)

Imfinzi (durvalumab)

MA08.123f, Durvalumab (Imfinzi®) and Tremelimumab-actl (Imjudo®)

MA08.173a, Tislelizumab-jsgr (Tevimbra®)

MA08.123e, Durvalumab (Imfinzi®) and Tremelimumab-actl (Imjudo®)