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AetnaCommercial · Prior Auth · Medical Policy · Hematology, OncologyMedium impact

Mosunetuzumab-axgb (Lunsumio and Lunsumio Velo) (CPB 1025, reviewed 2026-04-24)

Effective date
Not stated in the notice
Identified
Aug 16, 2026

Summary

Aetna considers mosunetuzumab-axgb (Lunsumio or Lunsumio Velo) medically necessary for follicular lymphoma when the disease had a partial response or no response to treatment or is relapsed or progressive, and the member has tried at least 2 prior lines of systemic therapy. It is also medically necessary for subsequent treatment of diffuse large B-cell lymphoma, high-grade B-cell lymphoma, HIV-related B-cell lymphomas and monomorphic post-transplant lymphoproliferative disorders (B-cell type) when the disease is relapsed or refractory and the drug will be used with polatuzumab vedotin (Lunsumio IV only). Continuation is medically necessary for up to 17 cycles total when there is no evidence of unacceptable toxicity or disease progression.

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What to do

Action · 6 steps
01Billing team: Precertification of Lunsumio and Lunsumio Velo is required for Aetna participating providers and members in applicable plan designs.
02Call (866) 752-7021 or fax (888) 267-3277 to request it, and see Specialty Pharmacy Precertification for the Statement of Medical Necessity forms.
03Bill J9350 (1 mg) for members who meet the criteria above, using ICD-10 codes C82.00 - C82.99 for follicular lymphoma.
04For DLBCL (C83.30 - C83.3A) and PTLD (D47.Z1), the source covers these codes only when used with polatuzumab vedotin, which is billed as J9309.
05Providers: For Lunsumio IV, follow the cycle 1 to cycle 3 and beyond dosing schedule in the prescribing information, and give up to 8 cycles, or 17 cycles total if a partial response or stable disease is achieved after 8 cycles.
06Lunsumio Velo is given only as a subcutaneous injection, with premedication to reduce the risk of cytokine release syndrome, on 21-day cycles.

Codes mentioned

J9350J9309C82.00C82.99C83.30C83.3AC83.80C83.8AD47.Z1964019641396417

Original notice

Mosunetuzumab-axgb (Lunsumio and Lunsumio Velo) (CPB 1025, reviewed 2026-04-24)
aetna.com · Always check the source before changing claims.
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Related policy hubs

Aetna policiesHematologyOncologyCode J9350Code J9309Code C82.00Code C82.99Code C83.30Code C83.3ACode C83.80Code C83.8ACode D47.Z1Code 96401Code 96413Code 96417

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