CommercialPrior AuthHigh impact
Talimogene Laherparepvec (Imlygic) (CPB 0900, reviewed 2026-04-14)
Aetna·Oncology, Dermatology, Radiation Oncology·Medical Policy
Effective date
Apr 14, 2026
We identified it
Aug 17, 2026
Summary
Aetna has updated its coverage policy for Talimogene Laherparepvec (Imlygic), an oncolytic viral therapy for melanoma and Merkel cell carcinoma. The policy establishes that precertification is mandatory for all commercial plans through the Aetna GCIT team, with specific approval criteria for melanoma (metastatic, unresectable, limited or borderline resectable lesions) and Merkel cell carcinoma (palliative treatment with prior anti-PD-L1/PD-1 progression). Combination therapy with immune checkpoint inhibitors (ipilimumab, pembrolizumab, nivolumab) remains experimental and not covered.
Action Required
IMMEDIATE: Billing team must implement mandatory precertification process for all Imlygic (J9325) claims on Aetna commercial plans. 1) Update billing system to flag all claims with CPT 11900, 11901, 96401, 96405, 96406 combined with J9325 and ICD-10 codes C43.0-C43.9 or C7B.1 as requiring prior authorization before submission. 2) Do NOT submit claims for Imlygic in combination with J9228 (ipilimumab), J9271 (pembrolizumab), or J9299 (nivolumab)—these combinations are not covered; contact providers to revise treatment plans. 3) Do NOT submit claims for Imlygic with diagnosis codes C44.92 (squamous cell carcinoma) or Z94.0-Z94.9 (transplant recipients)—these are excluded from coverage. 4) Providers must contact Aetna GCIT team at (866) 752-7021 or fax (888) 267-3277 for all precertification requests and submit Statement of Medical Necessity forms via Specialty Pharmacy Precertification. 5) Front desk staff must inform patients that precertification is required before treatment initiation. 6) Billing staff must document precertification approval number on all claims. Failure to obtain precertification will result in claim denials.