Tagraxofusp-erzs (Elzonris) (CPB 0947, reviewed 2026-05-28)

By May 28, 2026: Billing team must implement the following changes: (1) Update billing system to recognize HCPCS code J9269 (tagraxofusp-erzs injection, 10 mcg) as covered only when ICD-10 diagnosis codes C86.40 or C86.41 (blastic NK-cell lymphoma/BPDCN) are present on the claim; (2) Implement prior authorization requirement for J9269 claims to verify patient meets criteria (single-agent use for BPDCN, no unacceptable toxicity or disease progression); (3) Update charge entry templates to require providers to confirm first cycle is being administered in inpatient setting vs. subsequent outpatient cycles; (4) Deny or return claims with J9269 billed with any diagnosis code other than C86.40/C86.41 with explanation that all other indications are experimental/investigational; (5) Configure system to flag claims if J9269 is billed without documented evidence of continued response and acceptable tolerability for continuation cycles. Providers must ensure proper diagnosis coding and inpatient vs. outpatient setting designation at point of service. Failure to obtain required authorization or use incorrect diagnosis codes will result in claim denials for commercial Aetna plans.