CommercialCoverageMedium impact
08.02.05c, Retifanlimab-dlwr (Zynyz®)
Independence Blue Cross·PA · Oncology, Hematology, Pharmacy·Pharmacy
Effective date
Jul 1, 2025
We identified it
Jun 19, 2026
Summary
Independence Blue Cross updated policy 08.02.05c to 08.02.05d effective July 1, 2025, expanding coverage for retifanlimab-dlwr (Zynyz®) to include three new cancer indications: colon cancer, rectal cancer, and small bowel adenocarcinoma (all with specific molecular criteria). Merkel cell carcinoma criteria were also revised. ICD-10 diagnosis codes are no longer listed in the policy; billing teams must report the most appropriate diagnosis code supporting medical necessity based on policy criteria.
Action Required
By June 30, 2025: Billing team must update authorization and billing guidelines to reflect expanded indications for HCPCS code J9345 (retifanlimab-dlwr). Update prior authorization templates and clinical criteria in billing system to include new coverage for colon cancer, rectal cancer, and small bowel adenocarcinoma per NCCN V2.2025/V3.2025 guidelines. Ensure providers document molecular testing results (dMMR/MSI-H or POLE/POLD1 mutation status with TMB >50 mut/Mb) and appropriate disease stage/scenario on claims. Train billing and authorization staff on new indications and revised Merkel cell carcinoma criteria. Verify that claims include appropriate ICD-10 diagnosis codes that align with covered indications listed in policy. Implement logic to verify patients are 18+ years old and meet all specified medical necessity criteria before claim submission.