CommercialAdministrativeMedium impact
08.01.59f, Polatuzumab vedotin-piiq (Polivy®)
Independence Blue Cross·Oncology, Hematology, Pharmacy·Pharmacy
Effective date
Dec 29, 2025
We identified it
Jun 19, 2026
Summary
Policy 08.01.59f updates medical necessity criteria and medical coding requirements for Polatuzumab vedotin-piiq (Polivy®), a CD79b-directed cytotoxic immunoconjugate used in hematologic malignancies. The billing team must implement new documentation and coding standards effective immediately to ensure claim adjudication compliance.
Action Required
By December 29, 2025: Billing and clinical teams must obtain and review the full policy text at https://medpolicy.ibx.com/ibc/Commercial/Pages/Site-Activity-View.aspx?FilterField1=MPSiteActivityLogMonth&FilterValue1=12&FilterField2=MPSiteActivityLogYear&FilterValue2=2025#commercial-08-01-59f to identify specific medical necessity criteria and coding requirements for Polivy® claims. Update prior authorization workflows and documentation templates to reflect new criteria. Notify oncology providers of updated requirements. Ensure all Polivy® claims submitted on or after 12/29/2025 include required medical necessity documentation. Claims lacking updated documentation may be denied. Verify HCPCS J-code assignment (likely J9309 for Polivy®) aligns with new policy coding guidance.