Medicare AdvantageCoverageMedium impact
MA08.161c, Retifanlimab-dlwr (Zynyz®)
Independence Blue Cross·Oncology, Pharmacy, Hematology·Pharmacy
Effective date
Jul 1, 2025
We identified it
Jun 19, 2026
Summary
Independence Blue Cross Medicare Advantage policy MA08.161d (effective 07/01/2025) expands coverage for retifanlimab-dlwr (Zynyz®) to include three new cancer indications: colon cancer, rectal cancer, and small bowel adenocarcinoma, aligned with updated NCCN guidelines. Coverage criteria for Merkel cell carcinoma have also been revised. All ICD-10 codes have been removed from the policy; providers must report the most appropriate diagnosis code supporting medical necessity.
Action Required
By June 30, 2025: Billing team must update coverage criteria in billing system to reflect three new covered cancer indications (colon, rectal, small bowel adenocarcinoma) for HCPCS code J9345. Providers must verify patient meets medical necessity criteria per updated policy before submitting claims. Billing team should verify the appropriate ICD-10 diagnosis codes are reported on all claims for J9345 (colon cancer, rectal cancer, small bowel adenocarcinoma, anal carcinoma, appendiceal neoplasms, or Merkel cell carcinoma per policy criteria). Update prior authorization workflows if applicable. Claims submitted after 07/01/2025 without appropriate diagnosis codes supporting medically necessary criteria will be denied.