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Ipilimumab (Yervoy) (CPB 0815, reviewed 2026-07-16)
Effective date
Not stated in the notice
Identified
Aug 15, 2026
Replaced. This version was replaced by Ipilimumab (Yervoy) (CPB 0815, reviewed 2026-10-26) (published Oct 26, 2026).
Summary
Aetna's Clinical Policy Bulletin 0815 covers ipilimumab (Yervoy) for commercial medical plans. It considers ipilimumab medically necessary for the cancer indications listed in the policy, many of them in combination with nivolumab, and considers continued treatment medically necessary for members requesting reauthorization when there is no evidence of unacceptable toxicity or disease progression. It considers ipilimumab experimental, investigational, or unproven for indications such as glioblastoma, pancreatic cancer, and prostate cancer, and for use with bevacizumab, vemurafenib, dabrafenib, or trametinib.
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What to do
Action · 8 steps
01Billing team: Ipilimumab (Yervoy) requires precertification for all Aetna participating providers and members in applicable plan designs.
02Call (1) 752-7021 or fax (2) 267-3277, and use the Statement of Medical Necessity forms under Specialty Pharmacy Precertification.
03The Site of Care Utilization Management Policy also applies.
04HCPCS J9228 (injection, ipilimumab, 1 mg) is covered only if the selection criteria are met.
05Bevacizumab (J9035) is considered experimental and investigational when used in combination with ipilimumab.
06Related CPT codes in the policy are 81210, 81301, 88342, +88341, 96413, 96415 and 96417.
07Reauthorization requires no evidence of unacceptable toxicity or disease progression on the current regimen, and continued treatment is limited to the maximum durations listed by indication in the policy.
08Under Aetna commercial benefit plans, services that are more costly than an alternative at least as likely to produce equivalent results are considered not medically necessary.
Codes mentioned
81210813018834288341964139641596417J9228J9035J9206J9263J9271J9299Q5107C15.3C15.9C16.0C16.9C17.0C17.9C18.0C18.9C19C20C21.0C21.1C22.0C22.1C23C24.0C24.9C34.00C34.92C41.0C41.9C43.0C43.9C45.0C45.1C45.2C45.7C46.0C46.9C48.1C48.2C48.8C49.0C49.9C50.011C50.A2C51.0C51.9C52C53.0C53.9C54.0C54.9C55C56.1C56.9C57.00C57.02C58C64.1C64.9C69.30C69.32C69.40C69.42C74.00C74.92C79.31D03.0D03.9D18.00D18.09D48.60D48.62
Original notice
Ipilimumab (Yervoy) (CPB 0815, reviewed 2026-07-16)
aetna.com · Always check the source before changing claims.
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