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Ipilimumab (Yervoy®)
BCBS Tennessee·Oncology, Radiation Oncology·Medical Policy
Effective date
Dec 1, 2026
We identified it
Sep 11, 2026
Summary
This is a comprehensive new medical policy for Ipilimumab (Yervoy®) that establishes coverage criteria for multiple cancer indications, including FDA-approved uses (melanoma, RCC, colorectal cancer, HCC, NSCLC, mesothelioma, esophageal cancer) and compendial uses across 30+ cancer types. The policy requires prior authorization with specific documentation of tumor molecular status (MSI-H, dMMR, POLE/POLD1, TMB-H, PD-L1 expression) and genetic testing results where applicable. Implementation is delayed until December 1, 2026.
Action Required
By November 15, 2026: Billing and prior authorization teams must prepare for implementation of this new Ipilimumab policy. REQUIREMENTS: (1) Billing team: Configure prior authorization workflow in billing system to route all Ipilimumab claims for mandatory pre-authorization based on cancer diagnosis and indication; (2) Clinical documentation team: Create checklist requiring submission of molecular tumor testing results (MSI-H, dMMR, POLE/POLD1 status, TMB-H determination, PD-L1 expression ≥1% where applicable) and genetic testing documentation (EGFR exon 19 deletion, exon 21 L858R, ALK, RET, ROS1 status) before authorization can be granted; (3) Provider education: Distribute policy summary to oncology practices emphasizing that authorization is limited to 6 months per indication and may require specific combination therapy protocols (e.g., 4 doses of Ipilimumab followed by single-agent nivolumab); (4) Prior authorization team: Establish criteria-based approval matrix for each covered indication matching the 30+ cancer types listed; (5) Update all encounter forms and EMR templates used by oncology providers to include required molecular testing fields. CONSEQUENCES: Claims submitted without required prior authorization and complete molecular/genetic documentation will be denied. Do not implement any aspects of this policy before 12/1/26.