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AetnaCommercial · Prior Auth · Medical Policy · Endocrinology, Oncology, Rheumatology +1 moreMedium impact

Denosumab (CPB 0804, reviewed 2026-06-08)

Effective date
Not stated in the notice
Identified
Aug 13, 2026

Summary

Aetna's commercial medical policy sets coverage criteria for Prolia and its biosimilars and for Xgeva and its biosimilars, and precertification is required for these products in applicable plan designs. Prolia and its biosimilars are considered medically necessary for postmenopausal osteoporosis, osteoporosis in men, glucocorticoid-induced osteoporosis, bone loss in men receiving androgen deprivation therapy for prostate cancer, bone loss in women receiving adjuvant aromatase inhibitor therapy for breast cancer, and inhibiting progression of bone erosion in rheumatoid arthritis. Xgeva and its biosimilars are considered medically necessary for multiple myeloma, bone metastases from a solid tumor, giant cell tumor of bone, hypercalcemia of malignancy refractory to intravenous bisphosphonate therapy, and second-line therapy for osteopenia or osteoporosis in systemic mastocytosis. All other indications are considered experimental, investigational, or unproven, and combination therapy of denosumab with intravenous bisphosphonates is also considered experimental, investigational, or unproven.

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What to do

Action · 11 steps
01Get precertification for denosumab products (Prolia, Xgeva, or their biosimilars) for commercial members in applicable plan designs.
02Precertification is requested by phone at (1) 752-7021 or by fax at (2) 267-3277, and Statement of Medical Necessity forms are under Specialty Pharmacy Precertification.
03Billing team: confirm each request meets the initial approval criteria for the indication, such as a history of fragility fracture or a pre-treatment T-score less than or equal to -2.5 for postmenopausal osteoporosis, or a diagnosis of multiple myeloma or bone metastases from a solid tumor for Xgeva.
04For continuation of Prolia, document less than 24 months of therapy without clinically significant adverse events, or 24 months or more of therapy with improvement or stabilization in T-score since the previous bone mass measurement and no adverse effects.
05For continuation of Xgeva, document disease stability or disease improvement.
06Stop scheduling denosumab for members with uncorrected preexisting hypocalcemia, and stop scheduling denosumab combined with intravenous bisphosphonates, because the policy considers both experimental, investigational, or unproven.
07Stop billing denosumab for indications the policy lists as experimental, investigational, or unproven, such as cancer pain, Paget's disease of bone, and hyperparathyroidism.
08Bill the HCPCS code listed for each product, for example Q5136 for denosumab-bbdz (Jubbonti/Wyost); denosumab-adet (Ponlimsi) has no specific code and uses J0897.
09Approvals may be subject to dosing limits, see Medical Specialty Medication Quantity Limits.
10Check whether the Site of Care Utilization Management Policy applies.
11Watch for the next policy review, scheduled for 12/10/2026.

Codes mentioned

96372J0897Q5136Q5157Q5158Q5159Q5161Q5162Q5165Q5166Q5167Q5171C50.011C50.A2C61M05.60M06.9M81.0M81.8Z79.811Z87.310Z87.311Z87.312Z87.81C33C34.92C40.00C41.9C73C79.51C79.52C90.00C90.02C96.21D47.02E83.52

Original notice

Denosumab (CPB 0804, reviewed 2026-06-08)
aetna.com · Always check the source before changing claims.
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Related policy hubs

Aetna policiesEndocrinologyOncologyRheumatologyHematologyCode 96372Code J0897Code Q5136Code Q5157Code Q5158Code Q5159Code Q5161Code Q5162Code Q5165Code Q5166Code Q5167Code Q5171Code C50.011Code C50.A2Code C61Code M05.60Code M06.9Code M81.0Code M81.8Code Z79.811Code Z87.310Code Z87.311Code Z87.312Code Z87.81Code C33Code C34.92Code C40.00Code C41.9Code C73Code C79.51Code C79.52Code C90.00Code C90.02Code C96.21Code D47.02Code E83.52

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