CommercialPrior AuthMedium impact
Zanidatamab-hrii (Ziihera) (CPB 1075, reviewed 2025-12-19)
Aetna·Oncology, Gastroenterology, General Surgery·Medical Policy
Effective date
Mar 14, 2025
We identified it
Aug 19, 2026
Summary
Aetna has established coverage for zanidatamab-hrii (Ziihera) for HER2-positive biliary tract cancer with specific criteria: unresectable or resected gross residual (R2) disease or metastatic disease. All uses require precertification before treatment. Billing teams must ensure precertification is obtained and use the correct HCPCS code J9276 for the drug, along with appropriate premedication and infusion administration codes.
Action Required
By March 14, 2025: Billing team must implement the following: (1) Establish precertification requirement for all Aetna patients receiving zanidatamab-hrii—contact Aetna at (866) 752-7021 or fax (888) 267-3277 BEFORE treatment begins; (2) Update billing system to recognize HCPCS code J9276 (zanidatamab-hrii, 2 mg) as a covered code ONLY when linked to ICD-10 codes C22.1, C23, C24.0, C24.8, or C24.9 AND disease status is unresectable/R2/metastatic HER2-positive (IHC 3+); (3) Ensure providers document HER2 status (IHC 3+) and disease classification in medical records—claims without this documentation will be denied; (4) Add premedication codes (J0131-J0138, J1200-J1201, J2550, J3410, J0702, J1020, J1030, J1040, J1094, J1100, J1700, J1710, J1720, J7509, J7510, J7512, J8540) to encounter forms for infusions; (5) Pair drug administration with CPT 96413 (first hour) and CPT 96415 (each additional hour) on claims. Flag any claims for zanidatamab-hrii WITHOUT prior authorization for denial. This policy applies to Aetna commercial plans only—Medicare beneficiaries follow separate Medicare Part B criteria.