CommercialCoverageMedium impact
08.01.79f, Dostarlimab-gxly (Jemperli)
Independence Blue Cross·Oncology, Pharmacy·Pharmacy
Effective date
May 19, 2025
We identified it
Jun 19, 2026
Summary
Independence Blue Cross updated policy 08.01.79f to version 08.01.79g, effective 05/19/2025, adding anal carcinoma as a new covered indication for dostarlimab-gxly (Jemperli) and revising medical necessity criteria for six existing cancer types (colon, rectal, esophageal, gastric, pancreatic, small bowel, and uterine cancers) based on updated NCCN guidelines. All ICD-10 codes were removed from the policy document; billing teams must now independently identify and report appropriate diagnosis codes for each cancer indication.
Action Required
By May 19, 2025: (1) Billing team must update clinical documentation requirements to capture the new anal carcinoma indication and revised criteria for the six updated cancer types. (2) Ensure providers document specific NCCN guideline alignment (Anal Carcinoma V2.2025, Colon Cancer V1.2025, Rectal Cancer V1.2025, Esophageal V5.2024, Gastric V5.2024, Pancreatic V2.2025, Uterine V2.2025). (3) Providers and billing staff must independently verify and report the most appropriate ICD-10 diagnosis code(s) for each patient's specific cancer type and stage to support medical necessity, as codes are no longer listed in the policy. (4) Update billing system edits and prior authorization workflows for J9272 to reflect the expanded anal carcinoma coverage and revised criteria for other indications. (5) Review paclitaxel/carboplatin combination therapy scenarios for anal carcinoma (inguinal node recurrence, metastatic disease, locoregional disease) to ensure proper coding and authorization. Failure to submit correct diagnosis codes and meet revised criteria will result in claim denials.