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AetnaCommercial · Coverage · Medical Policy · Oncology, HematologyMedium impact

Gemtuzumab Ozogamicin (Mylotarg) (CPB 0922, reviewed 2026-05-28)

Effective date
Not stated in the notice
Identified
Aug 15, 2026

Summary

Aetna's policy for gemtuzumab ozogamicin (Mylotarg) covers the drug for commercial medical plans when it treats acute myeloid leukemia (AML) or acute promyelocytic leukemia (APL) and the tumor is CD33-positive, as confirmed by testing or analysis that identifies the CD33 antigen. Continuation of therapy is covered for members with an indication listed under Criteria for Initial Approval when there is no evidence of unacceptable toxicity or disease progression on the current regimen. Acute lymphoblastic leukemia, Hodgkin lymphoma, non-Hodgkin lymphoma and solid tumors are listed as experimental, investigational or unproven.

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What to do

Action · 6 steps
01Billing team: Bill HCPCS J9203 (injection, gemtuzumab ozogamicin, 0.1 mg) only when the selection criteria are met.
02Claims need documentation that the tumor is CD33-positive, confirmed by testing or analysis that identifies the CD33 antigen.
03Covered ICD-10 codes are C92.40 through C92.42 (acute promyelocytic leukemia), C92.60 through C92.62, and C92.A0 through C92.A2 (acute myeloid leukemia).
04For continuing therapy, the member must have an indication listed under Criteria for Initial Approval and must show no evidence of unacceptable toxicity or disease progression on the current regimen.
05Related chemotherapy administration codes are 96413 through 96417.
06This policy covers commercial medical plans only; Medicare criteria are in the Medicare Part B Criteria document.

Codes mentioned

J92039641396417C92.40C92.42C92.60C92.61C92.62C92.A0C92.A1C92.A2

Original notice

Gemtuzumab Ozogamicin (Mylotarg) (CPB 0922, reviewed 2026-05-28)
aetna.com · Always check the source before changing claims.
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Related policy hubs

Aetna policiesOncologyHematologyCode J9203Code 96413Code 96417Code C92.40Code C92.42Code C92.60Code C92.61Code C92.62Code C92.A0Code C92.A1Code C92.A2

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