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
AetnaCommercial · Prior Auth · Medical Policy · OncologyMedium impact

Durvalumab (Imfinzi) (CPB 0917, reviewed 2026-09-25)

Effective date
Not stated in the notice
Identified
Sep 30, 2026

Summary

Aetna covers durvalumab (Imfinzi) for commercial medical plans and considers it medically necessary for the listed cancer indications when that indication's criteria are met, including lung, small cell lung, biliary tract, cervical, colorectal, ampullary, pleural mesothelioma, hepatocellular, gastric, GEJ, esophageal, endometrial, bladder, and small bowel cancers. Members who have experienced disease progression while on PD-1 or PD-L1 inhibitor therapy are not considered eligible, and Aetna considers all other indications experimental, investigational, or unproven. Continuation of therapy is covered under separate reauthorization criteria that require no evidence of unacceptable toxicity or disease progression, with stated limits such as up to 12 months for unresectable stage II or III NSCLC and up to 24 months total for limited stage SCLC.

Get alerts when payers change rules like this one

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

Get Aetna alertsPolicy Monitoring is free. No card required.

What to do

Action · 8 steps
01Billing team: precertification of durvalumab (Imfinzi) is required of all Aetna participating providers and members in applicable plan designs.
02The source lists the precertification phone number (1) 752-7021 and fax (2) 267-3277, and Statement of Medical Necessity precertification forms under Specialty Pharmacy Precertification.
03Confirm that each J9173 (durvalumab, 10 mg) claim matches a listed indication and its criteria, such as EGFR exon 19 deletion and exon 21 L858R status for NSCLC, dMMR status for endometrial carcinoma used with carboplatin and paclitaxel, or dMMR/MSI-H status for gastric, GEJ, or esophageal adenocarcinoma used with tremelimumab-actl for neoadjuvant treatment.
04Members who experienced disease progression while on PD-1 or PD-L1 inhibitor therapy are excluded, so the record needs to show that this does not apply.
05Site of Care Utilization Management Policy applies to these infusions.
06Approvals may be subject to dosing limits in accordance with FDA-approved labeling, and the source lists the infusion as IV over 60 minutes.
07For continuation requests, the record needs to show no evidence of unacceptable toxicity or disease progression on the current regimen.
08The VENTANA PD-L1 (SP263) Assay is medically necessary for PD-L1 assessment in urothelial carcinoma tissue and has no specific CPT code.

Codes mentioned

J9173C23C45.0D09.0C37C76.0D15.0

Original notice

Durvalumab (Imfinzi) (CPB 0917, reviewed 2026-09-25)
aetna.com · Always check the source before changing claims.
View original ↗

Related changes

See all Aetna changes →
Durvalumab (Imfinzi) (CPB 0917, reviewed 2026-06-25)MediumNo effective date · Medical PolicyAvelumab (Bavencio) (CPB 0916, reviewed 2026-10-14)MediumNo effective date · Medical PolicyPaclitaxel, Albumin-Bound (CPB 0834, reviewed 2026-05-28)MediumNo effective date · Medical PolicyAvelumab (Bavencio) (CPB 0916, reviewed 2025-10-09)MediumNo effective date · Medical PolicyBrowse every Aetna change in the policy list

Related policy hubs

Aetna policiesOncologyCode J9173Code C23Code C45.0Code D09.0Code C37Code C76.0Code D15.0

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