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08.02.41a, Datopotamab deruxtecan (Datroway®)
Effective date
Nov 2, 2026
Identified
Nov 3, 2026
Summary
Independence Blue Cross updated policy 08.02.41a for datopotamab deruxtecan-dlnk (Datroway®) effective 11/02/2026 to align with FDA labeling and NCCN guidelines. The policy adds 13 new ICD-10 diagnosis codes for lung and breast cancers and expands covered indications for the drug across invasive breast cancer, inflammatory breast cancer, unresectable or metastatic breast cancer, and non-small cell lung cancer, with HER2 testing requirements specified.
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What to do
Action · 4 steps
01Effective 11/02/2026: Update charge entry and claim submission processes to ensure that when billing J9011 (datopotamab deruxtecan-dlnk) for Independence Blue Cross Commercial members, the claim includes one of the newly added ICD-10 diagnosis codes (C33, C34 series for lung cancer; C50 series for breast cancer) that aligns with the patient's diagnosis and the covered indication stated in the policy.
02Billing team must attach or reference documentation of HER2 protein expression test results (IHC or ISH) from an accredited laboratory to support medical necessity, as the policy requires FDA-approved HER2 testing for all indications.
03Providers should ensure that chart documentation includes the specific line of therapy, prior treatments received, PD-L1 status (if applicable), BRCA status (if applicable), and reason the patient is not a candidate for alternative therapies (e.g., fam-trastuzumab deruxtecan-nxki or PD-1/PD-L1 inhibitors), as these details determine coverage under the new criteria.
04Claims without the correct diagnosis codes and HER2 test documentation will be denied for lack of medical necessity.
Codes mentioned
J9011C33C34.01C34.02C34.11C34.12C34.2C34.31C34.32C34.81C34.82C34.91C34.92C50.011C50.012C50.021C50.022C50.111C50.112C50.121C50.122C50.211C50.212C50.221C50.222C50.311
Original notice
08.02.41a, Datopotamab deruxtecan (Datroway®)
medpolicy.ibx.com · Always check the source before changing claims.
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Related policy hubs
Independence Blue Cross policiesOncologyPharmacyCode J9011Code C33Code C34.01Code C34.02Code C34.11Code C34.12Code C34.2Code C34.31Code C34.32Code C34.81Code C34.82Code C34.91Code C34.92Code C50.011Code C50.012Code C50.021Code C50.022Code C50.111Code C50.112Code C50.121Code C50.122Code C50.211Code C50.212Code C50.221Code C50.222Code C50.311