CommercialPrior AuthHigh impact
Loncastuximab Tesirine-lpyl (Zynlonta) (CPB 0994, reviewed 2026-09-15)
Aetna·Hematology, Oncology·Medical Policy
We identified it
Oct 3, 2026
Summary
Aetna has updated its clinical policy for Loncastuximab Tesirine-lpyl (Zynlonta) effective immediately, establishing coverage criteria for four specific B-cell lymphoma indications: large B-cell lymphoma (after 2+ prior lines of therapy), histologic transformation of indolent lymphomas (after anthracycline treatment), HIV-related B-cell lymphomas (after 2+ prior lines), and post-transplant lymphoproliferative disorders (after 2+ prior lines). All uses require precertification before administration.
Action Required
Immediately: (1) Billing team must implement mandatory precertification requirement for all Zynlonta claims before drug administration—contact Aetna at (866) 752-7021 or fax (888) 267-3277 for all applicable plan designs. (2) Update billing system to flag HCPCS code J9359 claims requiring prior authorization with verification of: two or more prior systemic therapy lines (for DLBCL, HIV-related lymphomas, PTLD) OR anthracycline treatment plus non-transplant candidacy (for transformation cases), AND single-agent use. (3) Providers must document diagnosis using ICD-10 codes C83.30–C83.3A (DLBCL) or D47.Z1 (PTLD) and treatment history to support medical necessity at time of precertification submission. (4) Update encounter forms and EMR templates to capture prior therapy line count and treatment responses (complete response, partial response, progressive, relapsed, or refractory status). Claims submitted without prior authorization or failing to meet documented criteria will be denied.