Start free

PolicyChanges tracks payer policy changes for medical practices and tells you what to do before they take effect.

Create a free accountPolicy Monitoring is free. No card required.
← Back to list
Excellus BlueCross BlueShieldCommercial · Coverage · Cancer Treatment (Oncology) · NY · Oncology, Nuclear Medicine, Radiation Oncology +2 moreMedium impact

Radiopharmaceuticals for the Treatment of Cancer 6.01.44

Effective date
Sep 17, 2026
Identified
Sep 22, 2026

Summary

This medical policy sets when radiopharmaceutical cancer treatments are considered medically appropriate: Xofigo for castration-resistant prostate cancer with symptomatic bone metastases, Pluvicto for PSMA-positive metastatic castration-resistant prostate cancer, Lutathera for somatostatin receptor-positive neuroendocrine tumors, strontium-89 chloride for bone pain from confirmed skeletal metastases, and HICON for thyroid carcinoma. Treatment regimens beyond the U.S. Food and Drug Administration approved regimen are considered investigational. The current version is effective September 17, 2026, with an annual review, and the policy intent is unchanged.

Get alerts when payers change rules like this one

We check Excellus BlueCross BlueShield and other payers every day and email you when a change matches your specialty and state.

Get Excellus BlueCross BlueShield alertsPolicy Monitoring is free. No card required.

What to do

Action · 8 steps
01Already effective September 17, 2026: Claims for Xofigo (A9606) need documentation that the patient has medically or surgically castration-resistant prostate cancer, symptomatic bone metastases, and no known visceral metastatic disease or bulky regional lymph nodes greater than three cm on imaging performed within the past 30 days.
02Claims for Pluvicto (A9607) need documentation that the patient is PSMA-positive with metastatic castration-resistant prostate cancer, has been treated with at least one androgen-receptor pathway inhibitor (enzalutamide and/or abiraterone), has been treated with one or two taxane-based regimens or is considered appropriate to delay taxane-based chemotherapy, and has at least one PSMA-positive metastatic lesion and no PSMA-negative lesions on a PSMA PET/CT scan.
03Claims for Lutathera (A9513) need documentation of an eligible SSTR-positive tumor type, a Ki-67 below 20% for well-differentiated G1 or G2 tumors or below 55% for well-differentiated G3 tumors, positive somatostatin receptor scintigraphy with correlative CT or MRI, or a positive gallium-68 Dotate PET scan, and progression after somatostatin analogs.
04Documentation must also show the absence of these contraindications: serum creatinine of 1.7 mg per deciliter or greater or creatinine clearance below 50 mL per minute, hemoglobin of 8.0 g/dL or less, white blood cell count below 2000/mm3, and platelets below 75,000/mm3.
05For Lutathera without metastatic disease, documentation should include a surgical or medical consult and the reason for inoperability.
06Claims for strontium-89 chloride (A9600) need documentation of bone pain in patients with confirmed skeletal metastases.
07Claims for HICON (A9517, A9530) need documentation of one of the thyroid carcinoma criteria in the policy, such as remnant ablation after surgery in T1b/T2 localized disease, adjuvant therapy under the listed circumstances, or proven unresectable or metastatic disease.
08Treatment regimens in excess of the FDA approved regimen are considered investigational.

Codes mentioned

77750791017900579403963749637596409A4641A9513A9517A9530A9600A9606A9607C9399C61C79.51C79.52D40.0V58.0Z85.46

Original notice

Radiopharmaceuticals for the Treatment of Cancer 6.01.44
excellusbcbs.com · Always check the source before changing claims.
View original ↗

Related changes

See all Excellus BlueCross BlueShield changes →
Radiopharmaceuticals for the Treatment of Cancer 6.01.44MediumEffective Sep 17, 2026 · Cancer Treatment (Oncology)Magnetic Resonance Imaging (MRI) of the Prostate - (Effective Date - 2026-10-15) 6.01.46HighEffective Oct 15, 2026 · Radiology (x-rays) & ImagingLaboratory Testing for the Screening and Management of Prostate Cancer 2.02.48MediumEffective Sep 17, 2026 · Genetic Disease (Inherited Disease)Germline Genetic Testing for Hereditary Cancers 2.02.60MediumEffective Apr 16, 2026 · Genetic Disease (Inherited Disease)Browse every Excellus BlueCross BlueShield change in the policy list

Related policy hubs

Excellus BlueCross BlueShield policiesNY policy changesOncologyNuclear MedicineRadiation OncologyUrologyEndocrinologyCode 77750Code 79101Code 79005Code 79403Code 96374Code 96375Code 96409Code A4641Code A9513Code A9517Code A9530Code A9600Code A9606Code A9607Code C9399Code C61Code C79.51Code C79.52Code D40.0Code V58.0Code Z85.46

Summaries are AI-assisted. Always confirm against the original payer notice.

What is PolicyChanges

One workspace for payer rules, prior auth, coding and compliance

Medical practices use PolicyChanges to catch payer changes before they cause denials. Every change is summarized in plain English, with the codes involved, the date it takes effect and what to do.

Policy MonitoringPayer policy, prior auth and coding changes, filtered to your saved searchesOIG ScreeningStaff and vendors screened every month against OIG LEIE, SAM.gov and state Medicaid listsPrior Auth LookupKnow if a service needs prior authorization before you schedule itCredentialing TrackerLicenses, CAQH, Medicare revalidation and payer enrollments, with reminders before anything lapsesCompliance CenterKeep your HIPAA program documented and ready to show
Start freePolicy Monitoring is free. No card required.
Get alerts for changes like thisPolicy Monitoring is free. No card required.Create a free account