Polatuzumab Vedotin-piiq (Polivy) (CPB 0955, reviewed 2025-03-13)

By March 13, 2025: (1) Billing team must implement mandatory precertification workflow for all Polivy claims (J9309) by contacting Aetna at (866) 752-7021 or faxing (888) 267-3277 before treatment initiation. (2) Update billing system to enforce prior authorization requirements and reject claims that do not document one of the eight approved indications and clinical criteria (HIV-related B-cell lymphomas, DLBCL, HGBL, histologic transformation, or post-transplant lymphoproliferative disorders with specific ICD-10 codes C82.00-C88.41, D47.Z1). (3) Configure system to limit coverage to maximum 6 cycles (6 months) per authorization period and flag requests exceeding this threshold. (4) Providers must document specific approval criteria met (e.g., first-line R-CHP with IPI score >1, relapsed/refractory disease, transplant ineligibility, bridging to CAR-T, combination with mosunetuzumab-axgb) on all precertification requests using Statement of Medical Necessity forms. (5) Front desk staff must alert oncology providers that Polivy is experimental/investigational for all other indications outside the eight covered categories, and such uses will be denied. Failure to obtain precertification will result in automatic claim denial.