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Ibritumomab Tiuxetan (Zevalin) (CPB 0659, reviewed 2025-11-26)
Effective date
Not stated in the notice
Identified
Aug 15, 2026
Summary
Aetna considers ibritumomab tiuxetan (Zevalin) medically necessary for relapsed or refractory, low-grade or follicular B-cell non-Hodgkin's lymphoma (NHL), and for previously untreated follicular NHL in members who have achieved a partial or complete response to first-line chemotherapy. Aetna considers a repeat course of treatment not medically necessary and all other indications experimental, investigational, or unproven. This policy applies to commercial medical plans, and Medicare criteria are in a separate Medicare Part B Criteria document.
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What to do
Action · 6 steps
01Billing team: CPT 79403 and HCPCS A9543 are covered if the selection criteria are met, meaning the treatment is for relapsed or refractory, low-grade or follicular B-cell NHL, or for previously untreated follicular NHL in a member with a partial or complete response to first-line chemotherapy.
02ICD-10 codes C82.00 to C82.99 (follicular lymphoma) are covered on the same condition, while ICD-10 codes C22.0 and D47.Z1 are listed as not covered for the indications in the policy.
03Initiate the Zevalin regimen only after platelet counts recover to 150,000/mm3 or more, at least 6 weeks but no more than 12 weeks after the last dose of first-line chemotherapy.
04Do not administer the Zevalin regimen to members with platelet counts less than 100,000 cells/mm3.
05The maximum allowable dose of Y-90 Zevalin is 32.0 mCi regardless of body weight.
06Related codes listed in the policy are CPT 78800 to 78804, 85032, 85049 and 96401 to 96450.
Codes mentioned
79403A9543A9542788007880485032850499640196450C82.00C82.99C22.0D47.Z1
Original notice
Ibritumomab Tiuxetan (Zevalin) (CPB 0659, reviewed 2025-11-26)
aetna.com · Always check the source before changing claims.
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