CommercialCoverageHigh impact
Temozolomide (Temodar) Injection (CPB 0876, reviewed 2026-06-03)
Aetna·Oncology, Neurology, Hematology +3 more·Pharmacy
Effective date
Jun 3, 2026
We identified it
Aug 17, 2026
Summary
Aetna issued a comprehensive clinical policy bulletin for Temozolomide (Temodar) injection establishing covered indications for 13 specific cancer types and designating all other uses as experimental/investigational. This 1-day-old policy defines medical necessity criteria, dosing guidelines, and billing requirements for J9328 claims. Practices must verify patient diagnoses against the covered indication list before billing to avoid denials.
Action Required
By June 3, 2026: Billing team must implement controls in billing software to enforce Aetna's 13 covered indications for Temozolomide injection (CPT 96413, 96415 with HCPCS J9328). (1) Update claim edit logic to cross-reference patient ICD-10 diagnosis codes against the approved list: C71.0-C71.9 (glioblastoma, astrocytoma), C72.0-C72.9 (CNS neoplasms), C40.00-C41.9 (Ewing sarcoma), C43.0-C43.9 (cutaneous melanoma), C69.30-C69.92 (uveal melanoma), C84.00-C84.19 (mycosis fungoides/Sezary syndrome), C33-C34.92 (SCLC), C49.0-C49.9 (soft tissue sarcoma), C53.0-C55 and C54.0-C54.9 (uterine sarcoma), C25.0, C25.2, C25.4, C25.9 (neuroendocrine tumors), C74.00-C74.92 and C75.5-C75.6 (pheochromocytoma/paraganglioma), and other specified CNS metastases codes. (2) Flag or auto-deny claims with ICD-10 codes C18.0-C18.9 (colorectal cancer), C75.1 (pituitary tumors), C83.30-C83.3A (DLBCL), or C91.10-C91.12 (CLL) as non-covered experimental indications. (3) Provider education: Distribute covered indication list to all oncology, neurology, and hematology providers and medical staff to ensure proper diagnosis coding and treatment protocol alignment. (4) For continuation of therapy claims, add system reminder requiring verification of no unacceptable toxicity or disease progression documentation in medical records. Failure to implement these edits will result in claim denials and member appeals. Update encounter templates and prior authorization workflows accordingly.