CommercialPrior AuthHigh impact
Tisotumab Vedotin-tftv (Tivdak) (CPB 0998, reviewed 2026-01-13)
Aetna·Oncology, Hematology·Medical Policy
Effective date
Jan 13, 2026
We identified it
Aug 18, 2026
Summary
Aetna has issued a new medical policy (CPB 0998, effective 2026-01-13) establishing coverage criteria for Tisotumab Vedotin-tftv (Tivdak) for recurrent/metastatic cervical and vaginal cancers. The policy requires mandatory precertification before treatment and specifies approved indications, dosing, and administration protocols. Billing teams must implement prior authorization workflows and ensure claims include appropriate diagnosis and procedure codes.
Action Required
IMMEDIATE - Before billing any Tivdak claims effective 2026-01-13:
1. PRECERTIFICATION (MANDATORY):
- Billing/prior auth team: Update authorization protocols to REQUIRE precertification for all Tivdak (J9273) claims before administration
- Establish process to contact Aetna at (866) 752-7021 or fax (888) 267-3277 for all precertification requests
- Obtain Statement of Medical Necessity (SMN) precertification forms from Specialty Pharmacy Precertification portal
- DO NOT submit claims without proof of prior authorization; claims will be DENIED
2. COVERAGE VALIDATION:
- Billing team: Verify patient diagnosis code matches approved indications ONLY:
* Cervical cancer (C53.0-C53.9): Recurrent or metastatic with disease progression on/after chemotherapy
* Vaginal cancer (C52): Recurrent or metastatic, subsequent treatment
- All other indications are experimental/investigational and NOT covered
- Oncology providers: Document in medical record that cervical cancer patient meets criteria (disease progression post-chemotherapy) or has PD-L1 positive status if combination with pembrolizumab (J9271)
3. BILLING CODE UPDATES:
- Revenue cycle team: Update billing system to require diagnosis codes C52 or C53.x for HCPCS J9273
- Ensure chemotherapy administration codes (96413, 96415) are billed with Tivdak claims for IV infusion
- Link PD-L1 testing code 88360 to claims when pembrolizumab combination is used
4. DOSING VALIDATION:
- Providers/nurses: Confirm dosing is 2 mg/kg (maximum 200 mg) IV infusion over 30 minutes every 3 weeks
- Billing: Train staff that incorrect dosing may trigger claim denials
5. PLAN VERIFICATION:
- Front desk/eligibility: Verify patient has Aetna commercial coverage (Medicare criteria handled separately per policy)
- Confirm plan design allows Tivdak coverage; some plans may have exclusions
CONSEQUENCES: Claims submitted without prior authorization will be denied. Claims for non-covered indications will be denied. Incorrect dosing documentation may result in partial denials.