CommercialCoverageMedium impact
Necitumumab (Portrazza) (CPB 0898, reviewed 2026-07-02)
Aetna·Oncology, Pulmonology·Medical Policy
Effective date
Jul 2, 2026
We identified it
Aug 16, 2026
Summary
Aetna's updated Necitumumab (Portrazza) policy (CPB 0898, effective 2026-07-02) clarifies that coverage is limited to metastatic squamous non-small cell lung cancer (NSCLC) in combination with gemcitabine and cisplatin for commercial plans. All other indications—including non-squamous NSCLC, colorectal cancer, head and neck cancer, and combination therapies with abemaciclib or pembrolizumab—are considered experimental and not covered. Billing teams must ensure claims align with these narrow coverage criteria or face denials.
Action Required
By 2026-07-02: Billing team must update claim adjudication rules in billing software to enforce Aetna's narrow coverage criteria for Necitumumab (J9295). Implement hard stops to flag and reject claims that include: (1) ICD-10 codes C34.00-C34.92 WITHOUT metastatic squamous histology documentation; (2) non-squamous NSCLC diagnoses; (3) colorectal cancer (C19) or head/neck cancer (C76.0) diagnoses; (4) combination therapy claims with abemaciclib or pembrolizumab. Ensure all Portrazza claims include concurrent billing for gemcitabine (J9201, J9196, or J9184) and cisplatin (J9060) to verify compliant triple-therapy regimen. Train providers and coders that J9295 is ONLY payable for squamous NSCLC with documented metastatic disease and concurrent chemotherapy; deny all other indications automatically with denial reason 'Experimental/Investigational.' Update encounter templates to require providers to specify 'metastatic squamous NSCLC' at time of order. Claims submitted without this documentation will be denied as not meeting medical necessity criteria.