HCPCS Q5109 is officially defined as "Injection, infliximab-qbtx, biosimilar, (ixifi), 10 mg." HCPCS Q5109 is referenced in 10 tracked payer policy changes from PacificSource Health Plans, Missouri Medicaid (MO HealthNet), and 6 other payers. For billers and coders, staying current on payer-specific coverage criteria, reimbursement rules, and prior-authorization requirements for HCPCS Q5109 is critical to clean claim submission. Each entry below links to the full policy analysis with effective dates and action steps.
Effective November 30, 2026, PacificSource is adding six infliximab-based biologic medications (Remicade, Zymfentra, Inflectra, Renflexis, Ixifi, and Avsola) to its Infusion Services Site of Care prior authorization criteria for commercial plans. Billing teams must implement prior authorization requirements for these six HCPCS codes before the effective date.
MO HealthNet is changing preferred biosimilar medications effective October 1, 2026. Infliximab, Adalimumab, and Ustekinumab will have new preferred and non-preferred agent designations. Patients currently on non-preferred agents must switch to preferred versions unless an override is approved. Existing prior authorizations remain valid, but mandatory product switching will be enforced at the fiscal edit level.
Effective April 1, 2026, Walmart insurance will require prior authorization for all Bevacizumab, Infliximab, and Rituximab products (brand and biosimilars) across oncologic and non-oncologic indications. The policy establishes preferred biosimilar products (Mvasi, Zirabev, Avsola, Inflectra, Truxima, Riabni) that must be requested first, with non-preferred products (including Avastin, Remicade, Rituxan) requiring documented adverse events and FDA MedWatch reporting for exceptions.
Independence Blue Cross removed HCPCS code Q5109 (Injection, infliximab-qbtx, biosimilar, ixifi, 10 mg) from the Intravenous Infliximab and Related Biosimilars policy effective January 1, 2026. Billing teams must stop using this code for ixifi biosimilar claims and switch to alternative approved infliximab codes to avoid claim denials.
Aetna Better Health of Virginia is implementing five new clinical payment and coding policies effective October 1, 2025: (1) Multiple gestation diagnoses must include both complication and multiple gestation codes; (2) DME suppliers must have eligible referring/ordering NPIs; (3) NDC codes must match non-specific HCPCS drug codes; (4) Duplicate vaccine claims will be denied; (5) Infliximab for regional enteritis is limited to 5 administrations per 26 weeks. These policies will trigger claim denials if not followed.
Independence Blue Cross Medicare Advantage is deleting HCPCS code Q5109 (infliximab-qbtx biosimilar/Ixifi) from its intravenous infliximab coverage policy, effective 01/01/2026. Billing teams must stop using this code for MA claims and transition to alternative approved infliximab biosimilar codes (Q5103, Q5104, Q5121) or the reference product code (J1745).
For commercial medical plans, Aetna considers the following medically necessary for Dupuytren's contracture: collagenase clostridium histolyticum (Xiaflex, see CPB 1061), intralesional glucocorticoid injection in early-stage disease, ortho-voltage radiation for early-stage stage N and N/I disease, and percutaneous needle aponeurotomy when criteria are met. Percutaneous needle aponeurotomy is medically necessary for adults with a finger flexion contracture that has a palpable cord in a metacarpophalangeal or proximal interphalangeal joint, a contracture of at least 20 degrees, and a positive table top test, meaning the affected finger or fingers and the palm cannot be placed flat on a table at the same time. Aetna considers treatments such as anti-tumor necrosis factor therapy, autologous fat grafting, extracorporeal shock wave therapy, night-time splinting after fasciectomy or dermofasciectomy, the Digit Widget, and ultrasound therapy experimental, investigational, or unproven.
Aetna considers the treatments listed in this bulletin experimental, investigational or unproven for Alzheimer's disease because their effectiveness for that indication has not been established. The list includes acupuncture, applied behavior analysis, deep brain stimulation, gene therapy, intravenous immunoglobulins, lithium, music therapy, statins, stem cell therapy, transcranial magnetic and direct current stimulation, vagus nerve stimulation, and monoclonal antibodies such as solanezumab, bapineuzumab, crenezumab and semorinemab. The CPT, HCPCS and ICD-10 codes named in the bulletin are not covered for the indications the bulletin lists, including Alzheimer's disease (ICD-10 G30.0 through G30.9).
The IHCP reviewed the Outpatient Fee Schedule, found discrepancies, and will reflect the changes in the next regular update to that schedule. Codes listed twice on previous versions will appear only once, codes missing from the schedule are covered in the outpatient setting and can be billed for dates of service on or after the date listed for each code, and other listed codes are noncovered and will be added to the schedule. Codes that have been nationally end dated will be removed from the schedule, and Current Dental Terminology (CDT) codes cannot be billed on institutional claims (UB-04 claim form or electronic equivalent).
Effective January 1, 2019, Tisagenlecleucel code Q2042 and breast MRI codes 77046, 77047, 77048 and 77049 are now reviewed by AIM Specialty Health and require prior authorization, and A9584 (iodine I-123 ioflupane) is now reviewed for medical necessity and requires prior authorization. Breast MRI codes 77058 and 77059 are no longer reviewed by AIM Specialty Health, and the CAR-T codes 0537T through 0540T are listed as not reviewed and noncovered. Effective January 4, 2019, a long list of genetic testing codes beginning with 81120 and 81121 is now reviewed by AIM Specialty Health and requires prior authorization.
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