CommercialCoverageHigh impact
08.01.65e, Durvalumab (Imfinzi®) and Tremelimumab-actl (Imjudo®)
Independence Blue Cross·PA · Oncology, Pulmonology, Gastroenterology +2 more·Pharmacy
Effective date
Jul 28, 2025
We identified it
Jun 19, 2026
Summary
Independence Blue Cross updated policy 08.01.65e to version 08.01.65f, effective July 28, 2025. New medically necessary indications were added for bladder cancer and uterine neoplasms, and medical necessity criteria were revised for five cancer types (ampullary adenocarcinoma, biliary tract cancers, hepatocellular carcinoma, non-small cell lung cancer, and small cell lung cancer) based on updated NCCN guidelines. All ICD-10 diagnosis codes were removed from the policy document as informational only.
Action Required
By July 28, 2025: Billing team must update all prior authorization and billing workflows to reflect the expanded coverage indications for durvalumab (J9173) and tremelimumab-actl (J9347). (1) Review the complete revised policy 08.01.65f to understand new coverage for bladder cancer and uterine neoplasms. (2) Update clinical decision support systems and prior authorization templates to reflect revised medical necessity criteria for ampullary adenocarcinoma, biliary tract cancers, hepatocellular carcinoma, NSCLC, and SCLC. (3) Train providers and billing staff on the new indications and updated ECOG performance status requirements. (4) Update encounter forms and EMR templates to prompt providers for appropriate diagnosis coding in support of medical necessity. (5) Immediately cease using removed ICD-10 codes from the old policy version; report the most appropriate diagnosis code based on updated medical necessity criteria listed in policy 08.01.65f. Claims submitted without current medical necessity documentation may be denied or require rework.