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MA08.185a, Datopotamab deruxtecan (Datroway®)
Effective date
Nov 2, 2026
Identified
Nov 3, 2026
Summary
Independence Blue Cross updated Medicare Advantage policy MA08.185a effective 11/02/2026 to align datopotamab deruxtecan-dlnk (Datroway®) coverage with FDA labeling and NCCN guidelines for non-small cell lung cancer and breast cancer. The policy adds specific ICD-10 diagnosis codes and clarifies HER2 testing requirements and clinical eligibility criteria for coverage.
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What to do
Action · 4 steps
01Effective 11/02/2026: Update charge entry and claim submission processes to ensure that claims for J9011 (datopotamab deruxtecan-dlnk) for Independence Blue Cross Medicare Advantage members include the applicable ICD-10 diagnosis codes from the added list (C33, C34.01–C34.92, and C50.011–C50.311) and documentation of HER2 testing results.
02Instruct billing and clinical staff to confirm that prior to scheduling Datroway treatment, the member's chart contains evidence of HER2 protein expression testing by an FDA-approved diagnostic method (IHC or ISH) and that the clinical indication matches one of the covered scenarios (e.g., HR-positive HER2-negative breast cancer with prior endocrine and chemotherapy; TNBC with PD-L1 CPS <10 or ineligible for PD-1/PD-L1 inhibitors; inflammatory or unresectable/metastatic breast cancer; NSCLC per policy guidelines).
03Get prior authorization before submitting claims, as this is a specialty medication requiring medical necessity review.
04Retain the updated policy guidelines in your prior auth tracker and reference the specific HER2 testing standards (IHC accredited labs, FISH ratio thresholds, ISH signal counts) when communicating with providers to prevent claim denials for missing or non-compliant testing documentation.
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
MA08.185a, Datopotamab deruxtecan (Datroway®)
medpolicy.ibx.com · Always check the source before changing claims.
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Related policy hubs
Independence Blue Cross policiesOncologyHematologyPharmacyCode 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