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Independence Blue CrossCommercial · Documentation · Pharmacy · PA · Oncology, PharmacyMedium impact

08.01.72b, Pertuzumab, Trastuzumab, and Hyaluronidase-zzxf (Phesgo®)

Act
by Nov 17, 2025
Effective date
Nov 17, 2025
Identified
Jun 19, 2026

Summary

Independence Blue Cross updated policy 08.01.72b for Phesgo (pertuzumab, trastuzumab, and hyaluronidase-zzxf) effective 11/17/2025 to align with current FDA labeling and NCCN guidelines. All ICD-10 diagnosis codes were removed from the policy attachment; billing teams must now report the most appropriate diagnosis code supporting medical necessity rather than relying on a predefined code list.

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What to do

by Nov 17, 2025 · 6 steps
01Billing team must update claim submission procedures to remove reliance on the deleted ICD-10 code attachment A for Phesgo claims.
02For all Phesgo (J9316) claims submitted to Independence Blue Cross commercial plans on or after the effective date, verify that the most clinically appropriate ICD-10 diagnosis code is reported in support of one of the four covered indications listed in the policy (neoadjuvant early breast cancer, adjuvant early breast cancer, metastatic breast cancer with docetaxel, or substitute for IV pertuzumab/trastuzumab).
03Confirm HER2-positive status is documented (IHC 3+, FISH ratio >2.0, or other approved testing methods) and LVEF thresholds are met (>55% for neoadjuvant/adjuvant; >50% for metastatic or as substitute therapy).
04Update billing system templates and prior authorization workflows to remove references to Attachment A.
05Train coding and authorization staff on the new requirement to select diagnosis codes based on clinical presentation rather than a predetermined list.
06Claims lacking appropriate HER2 documentation or diagnosis code justification may be denied.

Codes mentioned

J9316

Original notice

08.01.72b, Pertuzumab, Trastuzumab, and Hyaluronidase-zzxf (Phesgo®)
medpolicy.ibx.com · Always check the source before changing claims.
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Related policy hubs

Independence Blue Cross policiesPA policy changesOncologyPharmacyCode J9316

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