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Ibritumomab Tiuxetan (Zevalin) (CPB 0659, reviewed 2026-10-15)
Effective date
Not stated in the notice
Identified
Oct 18, 2026
Summary
Aetna's Clinical Policy Bulletin 0659 covers ibritumomab tiuxetan (Zevalin) for commercial medical plans. Aetna considers it medically necessary for relapsed or refractory, low-grade or follicular B-cell non-Hodgkin lymphoma, and for previously untreated follicular non-Hodgkin lymphoma in members who have achieved a partial or complete response to first-line chemotherapy. Aetna considers all other indications experimental, investigational or unproven, and considers a repeat course of treatment not medically necessary.
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What to do
Action · 7 steps
01Billing team: Bill CPT 79403 and HCPCS A9543 for the Zevalin therapeutic regimen only when the selection criteria are met, and use the covered ICD-10 codes for relapsed or refractory, low-grade or follicular B-cell NHL, or previously untreated follicular NHL in members with a partial or complete response to first-line chemotherapy.
02Do not bill the regimen for the other listed indications, which Aetna considers experimental, investigational or unproven, or for a repeat course of treatment, which Aetna considers not medically necessary.
03Before starting the regimen, confirm the platelet count has recovered to at least 150,000/mm3 and that the regimen starts at least 6 weeks but no more than 12 weeks after the last dose of first-line chemotherapy.
04Do not give the regimen to members with platelet counts below 100,000 cells/mm3, and give it only in facilities with immediate access to resuscitative measures.
05Day 1: rituximab 250 mg/m2 IV.
06Day 7, 8 or 9: rituximab 250 mg/m2 IV, then within 4 hours give Y-90 Zevalin at 0.4 mCi/kg if platelets are at least 150,000/mm3, or at 0.3 mCi/kg for relapsed or refractory members with platelets of 100,000 to 149,000/mm3.
07The maximum Y-90 Zevalin dose is 32.0 mCi regardless of body weight.
Codes mentioned
79403A9543C82.00C82.99C83.00C83.09C83.30C83.3AC83.90C83.99C86.50C86.61C84.A0C84.99C22.0C83.80C83.89C83.10C83.19C83.70C83.79C88.40C88.41C91.10C91.12C91.90C91.92D47.Z1
Original notice
Ibritumomab Tiuxetan (Zevalin) (CPB 0659, reviewed 2026-10-15)
aetna.com · Always check the source before changing claims.
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Related policy hubs
Aetna policiesOncologyHematologyNuclear MedicineCode 79403Code A9543Code C82.00Code C82.99Code C83.00Code C83.09Code C83.30Code C83.3ACode C83.90Code C83.99Code C86.50Code C86.61Code C84.A0Code C84.99Code C22.0Code C83.80Code C83.89Code C83.10Code C83.19Code C83.70Code C83.79Code C88.40Code C88.41Code C91.10Code C91.12Code C91.90Code C91.92Code D47.Z1