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Sutimlimab-jome (Enjaymo) (CPB 1006, reviewed 2026-11-02)
Effective date
Not stated in the notice
Identified
Nov 5, 2026
Previous versions
- Sutimlimab-jome (Enjaymo) (CPB 1006, reviewed 2025-12-03) · published Dec 3, 2025
Summary
Aetna's clinical policy bulletin CPB 1006 (last reviewed 2026-11-02) governs precertification and medical necessity for sutimlimab-jome (Enjaymo) for commercial plans, limiting approval to primary cold agglutinin disease with specific lab criteria and requiring precertification by phone or fax. The practice must confirm precertification for Enjaymo (HCPCS J1302) before scheduling, ensure charts document the required diagnostic evidence and site-of-care review, and track continuation-of-therapy documentation for reauthorization.
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What to do
Action · 5 steps
01Billing team and providers: Before scheduling any sutimlimab-jome (Enjaymo) infusion for commercial Aetna members, obtain precertification by calling (866) 752-7021 or faxing (888) 267-3277 (or use the SMN precertification form), and record the authorization number in the prior auth tracker; the source states precertification is required of all participating providers in applicable plan designs.
02Providers should document in the chart the primary CAD diagnosis criteria (elevated LDH, low haptoglobin, positive polyspecific and C3d-positive DAT, cold agglutinin titer of 1:64 or higher at 4°C, IgG DAT of 1+ or less, and exclusion of secondary causes) so the claim for HCPCS J1302 with ICD-10 D59.12 is supported.
03Front desk staff should be told that Site of Care Utilization Management applies, so the practice should confirm the site-of-service requirement before scheduling infusion (CPT 96365–96368 administration).
04For reauthorization, the billing team should track documentation of response (hemoglobin improvement, hemolysis markers, reduced transfusions) and absence of unacceptable toxicity.
05Claims without precertification will be denied per the payer's applicable plan rules; the source does not specify a future deadline.
Codes mentioned
J1302D59.12861568615786880963659636696367963689641396417
Original notice
Sutimlimab-jome (Enjaymo) (CPB 1006, reviewed 2026-11-02)
aetna.com · Always check the source before changing claims.
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