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Cetuximab (Erbitux) (CPB 0684, reviewed 2025-12-03)
Effective date
Not stated in the notice
Identified
Aug 12, 2026
Summary
Aetna's commercial medical policy CPB 0684 covers cetuximab (Erbitux) for listed cancers when the member meets the criteria for that indication. Covered indications are colorectal cancer, head and neck cancer, non-small cell lung cancer, penile cancer and squamous cell skin cancer, each with its own conditions. Precertification is required. Aetna considers all other indications experimental, investigational or unproven.
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What to do
Action · 11 steps
01Billing team: Precertification of cetuximab (Erbitux) is required for all Aetna participating providers and members in applicable plan designs.
02Call (866) 752-7021 or fax (888) 267-3277 to request it, and use the Statement of Medical Necessity precertification forms where they apply.
03Confirm the request meets the criteria for an approved indication.
04For colorectal cancer, RAS (KRAS and NRAS) mutation status must be negative and the member must not have previously experienced clinical failure on panitumumab.
05If the tumor is BRAF V600E positive, cetuximab must be used with encorafenib (Braftovi).
06For first-line colon cancer, the tumor must be left-sided only.
07For KRAS G12C positive disease, cetuximab must be used with sotorasib (Lumakras) or adagrasib (Krazati) after prior chemotherapy.
08Claims for KRAS gene analysis (CPT 81275 and 81276) are covered when selection criteria are met.
09Approvals may be subject to dosing limits in accordance with FDA-approved labeling, accepted compendia and/or evidence-based practice guidelines.
10Cetuximab used in combination with Vectibix (panitumumab), Tarceva (erlotinib), Iressa (gefitinib), Avastin (bevacizumab) or natural killer cell therapy is considered experimental, investigational or unproven.
11For reauthorization, continuation of cetuximab is considered medically necessary when there is no evidence of unacceptable toxicity or disease progression on the current regimen.
Codes mentioned
J9055812758127688363C44.02C76.0C61C22.0Z85.038Z85.048
Original notice
Cetuximab (Erbitux) (CPB 0684, reviewed 2025-12-03)
aetna.com · Always check the source before changing claims.
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