CommercialPrior AuthMedium impact
Loncastuximab Tesirine-lpyl (Zynlonta) (CPB 0994, reviewed 2025-12-09)
Aetna·Hematology, Oncology·Medical Policy
Effective date
Dec 9, 2025
We identified it
Aug 16, 2026
Summary
Aetna has updated its clinical policy for Loncastuximab Tesirine-lpyl (Zynlonta) effective immediately, establishing coverage criteria for four B-cell lymphoma indications: relapsed/refractory large B-cell lymphoma, histologic transformation of indolent lymphomas, HIV-related B-cell lymphomas, and post-transplant lymphoproliferative disorders. All prescriptions require precertification before administration, and billing must use HCPCS code J9359 with appropriate chemotherapy administration codes.
Action Required
Effective immediately (2025-12-09): 1) Billing team must establish precertification requirement in billing system for all Zynlonta claims. Update claim submission workflow to require precertification documentation before processing. 2) Implement verification protocol requiring providers to submit Statement of Medical Necessity (SMN) forms to Aetna at (866) 752-7021 or fax (888) 267-3277 BEFORE administering Zynlonta. 3) Update encounter forms and EMR templates to require documentation of: disease status (relapsed/refractory/progressive/partial response/no response), prior treatment lines (minimum 2 required for most indications), and single-agent confirmation. 4) Configure billing software to validate ICD-10 codes C83.30-C83.39 and D47.Z1 match approved indications before claim submission. 5) Train coding staff on four covered indications and their specific eligibility criteria (different requirements for DLBCL vs. PTLD vs. HIV-related vs. transformed indolent lymphomas). 6) Notify oncology providers of new precertification requirement and submission process. Failure to obtain precertification will result in claim denials.