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Independence Blue CrossCommercial · Coverage · Pharmacy · PA · Oncology, Hematology, PharmacyMedium impact

08.01.75d, Margetuximab-cmkb (Margenza)

Effective date
Nov 18, 2024
Identified
Jun 19, 2026

Summary

Independence Blue Cross updated policy 08.01.75d for Margetuximab-cmkb (Margenza) to align with NCCN guidelines for HER2-positive breast cancer treatment. The policy was reissued during the annual review process on 05/28/2025, with a prior effective date of 11/18/2024 when ICD-10 codes with unspecified laterality were removed. Coverage criteria remain focused on fourth-line therapy and beyond for metastatic/recurrent breast cancer with documented HER2 protein overexpression.

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What to do

Action · 4 steps
01Billing team must verify that all Margetuximab-cmkb (Margenza) claims submitted on or after 11/18/2024 reference only ICD-10 diagnosis codes with laterality specified (left or right), removing any claims with unspecified laterality codes.
02Before submitting claims for J9353, ensure: (1) HER2 protein overexpression is confirmed via FDA-approved diagnostic test (IHC 3+, FISH ratio >2.0, or ISH); (2) patient has received at least two prior anti-HER2 regimens with at least one for metastatic disease, OR is receiving fourth-line therapy and beyond for metastatic/recurrent breast cancer; (3) documentation includes specific hormone receptor status and chemotherapy combination drug name.
03Update claim scrubbing rules in billing software to flag and reject any J9353 claims with unspecified laterality ICD-10 codes to prevent denials.
04Notify providers of the laterality requirement on claim submission forms.

Codes mentioned

J9353

Original notice

08.01.75d, Margetuximab-cmkb (Margenza)
medpolicy.ibx.com · Always check the source before changing claims.
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Related changes

See all Independence Blue Cross changes →
MA08.132e, Margetuximab-cmkb (Margenza)LowEffective Oct 1, 2025 · Pharmacy08.01.75e, Margetuximab-cmkb (Margenza)LowEffective Oct 1, 2025 · PharmacyMA08.132d, Margetuximab-cmkb (Margenza)MediumEffective May 28, 2025 · PharmacyMA08.132e, Margetuximab-cmkb (Margenza)LowEffective Oct 1, 2025 · PharmacyBrowse every Independence Blue Cross change in the policy list

Related policy hubs

Independence Blue Cross policiesPA policy changesOncologyHematologyPharmacyCode J9353

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