HCPCS J9350 is officially defined as "Injection, mosunetuzumab-axgb, 1 mg." HCPCS J9350 is referenced in 9 tracked payer policy changes from Capital Blue Cross, WellCare, and 4 other payers. For billers and coders, staying current on payer-specific coverage criteria, reimbursement rules, and prior-authorization requirements for HCPCS J9350 is critical to clean claim submission. Each entry below links to the full policy analysis with effective dates and action steps.
Capital Blue Cross is implementing new prior authorization requirements for three new specialty injectable drugs (Yartemlea, Lunsumio Velo, Rybrevant Faspro) effective May 1, 2026, and revising prior authorization requirements for dozens of existing specialty injectables effective June 1, 2026. The C9399 temporary code will now require prior authorization for many drugs previously covered without authorization.
Beginning January 1, 2026, the procedure codes in this Centene bulletin require prior authorization through Evolent, which manages prior authorizations for Centene in medical oncology, radiation oncology, pediatric and dose optimization, and cardiology. The change applies to all Ambetter (Marketplace), Medicaid and Medicare products offered by Centene. The code table includes anti-emetics, bone metastasis drugs, cancer treatment drugs, and supportive medications such as iron products, ESAs, myeloid growth factors and immune globulins.
Independence Blue Cross updated MA08.158c to expand Lunsumio (mosunetuzumab-axgb) coverage to include three new indications: Diffuse Large B-Cell Lymphoma, High-Grade B-Cell Lymphomas, and HIV-Related B-Cell Lymphomas, in addition to the existing Follicular Lymphoma coverage. Criteria for Classic Follicular Lymphoma were revised. All ICD-10 codes were removed from the policy; billing teams must report the most appropriate diagnosis code supporting medical necessity. Billing code remains J9350.
Independence Blue Cross expanded coverage for mosunetuzumab-axgb (Lunsumio) effective June 16, 2025, adding four new indications: Diffuse Large B-Cell Lymphoma, High-Grade B-Cell Lymphomas, HIV-Related B-Cell Lymphomas, and Post-Transplant Lymphoproliferative Disorders. Criteria for Classic Follicular Lymphoma were revised. ICD-10 diagnosis codes were removed from the policy; billing teams must report the most appropriate diagnosis code supporting medical necessity.
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'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.
Injectable oncology drugs under the medical benefit may be considered medically necessary when FDA-approved or compendia-supported use criteria are met, including NCCN Compendium level of evidence 1 or 2A, first-line failure or intolerance, required genetic testing, combination use where applicable, and dosage within program quantity limits. Many named agents, including Anktiva, Blenrep, Boruzu, Keytruda Qlex, Lymphir, and Lunsumio Velo, are listed as not covered on the State Health Plan Medical Drug Formulary. The 11/01/2026 update added coverage for Rybrevant Faspro (amivantamab and hyaluronidase-lpuj), the 10/19/2026 update added coverage for Tivdak (tisotumab vedotin-tftv), and the 06/15/2026 update added several agents to the not medically necessary list.
Prior authorization is required for the injectable oncology medications listed in this BCBSMS policy, and the requested agent must meet the policy's medical necessity criteria. The 10/19/2026 update added coverage for Tivdak (tisotumab vedotin-tftv), and the 11/01/2026 update added coverage for Rybrevant Faspro (amivantamab and hyaluronidase-lpuj) and listed Lunsumio Velo (mosunetuzumab-axgb) as a non-covered medication. Several other listed drugs are not medically necessary for all indications because other formulary alternatives are covered by the plan.
Effective September 1, 2023, Premera HMO added Zilretta (triamcinolone acetonide extended-release injectable suspension) as medically necessary for moderate to severe osteoarthritis pain of the knee in adults, approved once per knee per lifetime, and considers it investigational for all other indications. Effective August 4, 2023, Xgeva (denosumab) was added for the prevention of skeletal-related events in individuals with bone metastases from solid tumors and in individuals with multiple myeloma. Effective July 1, 2023, Premera HMO added medical necessity criteria for Veozah and Elfabrio, expanded Sotyktu trial and failure criteria to three of the listed agents, and made maternal serum biomarker tests for preeclampsia or spontaneous preterm birth investigational.
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