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Independence Blue CrossMedicare Advantage · Coverage · Pharmacy · PA · Oncology, PharmacyMedium impact

MA08.132d, Margetuximab-cmkb (Margenza)

Effective date
May 28, 2025
Identified
Jun 19, 2026

Summary

Independence Blue Cross reissued MA08.132d as MA08.132e on 05/28/2025 per annual review process. Key change from 11/18/2024 update: ICD-10 codes with unspecified laterality were removed from coverage criteria for margetuximab-cmkb (Margenza) in HER2-positive breast cancer. Coverage remains contingent on HER2 protein overexpression testing (IHC 3+, FISH >2.0, or ISH criteria) and use in fourth-line or later therapy with specific chemotherapy combinations.

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What to do

Action · 6 steps
01By 05/28/2025: Billing team must update claim submission systems to remove ICD-10 codes with unspecified laterality from margetuximab-cmkb (J9353) coverage determinations.
02Verify all breast cancer diagnosis codes on claims include specific laterality designations (left, right, or bilateral).
03Update prior authorization templates and clinical documentation requirements to reflect the revised ICD-10 code list (see Attachment A referenced in policy).
04Reject or route for correction any J9353 claims submitted with unspecified laterality codes.
05Train billing staff and providers on laterality coding requirements to prevent claim denials.
06Confirm HER2 testing documentation (IHC 3+, FISH ratio >2.0, or ISH criteria) is present before authorizing therapy.

Codes mentioned

J9353

Original notice

MA08.132d, 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 · PharmacyMA08.132e, Margetuximab-cmkb (Margenza)LowEffective Oct 1, 2025 · Pharmacy08.01.75d, Margetuximab-cmkb (Margenza)MediumEffective Nov 18, 2024 · PharmacyBrowse every Independence Blue Cross change in the policy list

Related policy hubs

Independence Blue Cross policiesPA policy changesOncologyPharmacyCode J9353

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