TL;DR: Aetna, a CVS Health company, modified CPB 0834 governing albumin-bound paclitaxel (Abraxane) coverage under commercial medical plans, with an effective date of September 26, 2025. If your team bills J9264 for Abraxane alongside chemotherapy administration codes like 96413–96417, review this update before submitting claims against the new policy.
CPB 0834 Aetna is the Clinical Policy Bulletin controlling when albumin-bound paclitaxel reimbursement is approved for commercial plan members — and it covers a wide range of oncology diagnoses spanning breast, pancreatic, lung, gastric, and biliary cancers. The Aetna albumin-bound paclitaxel coverage policy now reflects updated criteria that your billing team needs to map against current charge capture before the September 26 effective date.
Quick-Reference Table
| Field | Detail |
|---|---|
| Payer | Aetna, a CVS Health company |
| Policy | Paclitaxel, Albumin-Bound — CPB 0834 |
| Policy Code | CPB 0834 |
| Change Type | Modified |
| Effective Date | September 26, 2025 |
| Impact Level | High |
| Specialties Affected | Oncology, Hematology/Oncology, Infusion Therapy, Hospital Outpatient |
| Key Action | Verify J9264 claims pair with covered ICD-10 diagnoses and confirm prior authorization requirements are met before billing after September 26, 2025 |
Aetna Albumin-Bound Paclitaxel Coverage Criteria and Medical Necessity Requirements 2025
The Aetna albumin-bound paclitaxel coverage policy under CPB 0834 applies exclusively to commercial medical plans. Medicare members follow separate criteria — see Aetna's Medicare Part B step therapy guidelines, not this CPB.
Abraxane (J9264 — injection, paclitaxel protein-bound particles, 1 mg) is the covered HCPCS code under this policy when medical necessity criteria are satisfied. Medical necessity here is not a rubber stamp. Aetna expects documentation that supports the specific indication, treatment line, and combination regimen before approving claims.
The ICD-10 diagnosis list under this policy spans 411 codes — that's one of the broadest oncology code sets you'll see in a single CPB. Covered diagnoses include pancreatic cancer (C25.0–C25.9), breast cancer, non-small cell lung cancer, gastric cancer (C16.0–C16.9), biliary tract malignancies (C22.x–C24.x), and a long tail of other solid tumors including esophageal (C15.3–C15.9), small bowel (C17.x), hepatocellular, anal canal (C21.x), and head and neck primaries like nasopharyngeal (C11.x) and parotid gland (C07) cancers.
The breadth of the diagnosis list is both a feature and a trap. A wide ICD-10 scope gives your oncology billing team flexibility — but it also means Aetna has more room to deny claims where the specific sub-code doesn't map cleanly to the approved indication. Map your ICD-10 codes precisely. "Malignant neoplasm of pancreas" coded as C25.9 when the medical record specifies the head of the pancreas (C25.0) will get flagged.
Prior authorization is the gating mechanism here. Albumin-bound paclitaxel is a high-cost chemotherapy agent — the kind Aetna watches closely at the claim level. Before any infusion, confirm prior auth is in place and that the authorized indication matches what you're billing. A prior authorization obtained for one regimen does not automatically cover a different combination regimen billed under the same J9264 code.
Whether Aetna albumin-bound paclitaxel reimbursement is covered under a specific commercial plan also depends on plan-level benefit design. Some commercial plans exclude certain oncology drugs or require step therapy through conventional solvent-based paclitaxel (J9267) first. Check the member's benefit summary before assuming coverage.
Aetna Albumin-Bound Paclitaxel Exclusions and Non-Covered Indications
The policy data does not list a separate experimental or non-covered designation for J9264 itself — coverage is indication-driven. The real exclusion risk comes from off-label use cases that fall outside the 411 covered ICD-10 codes.
Conventional paclitaxel (J9267 — injection, paclitaxel, 1 mg) is listed as a related but separate code. Abraxane and conventional paclitaxel are not interchangeable under this policy. Billing J9264 when J9267 is the authorized agent — even for the same diagnosis — is a fast path to a claim denial. If your provider switches from solvent-based paclitaxel to Abraxane mid-regimen, get a new prior authorization before the next infusion.
Indications outside the covered ICD-10 list are not covered under CPB 0834. If a provider uses Abraxane for a diagnosis that doesn't appear in the covered code set, that claim will deny on medical necessity grounds regardless of what the clinical literature supports.
Coverage Indications at a Glance
| Indication | Status | Relevant Codes | Notes |
|---|---|---|---|
| Pancreatic cancer | Covered | J9264, C25.0–C25.9 | Medical necessity documentation required; often combined with gemcitabine (J9201/J9196) |
| Breast cancer | Covered | J9264 | Confirm specific ICD-10 sub-code matches authorized indication |
| Non-small cell lung cancer | Covered | J9264 | Combination regimens with carboplatin (J9045) are common; each agent needs separate authorization review |
| Gastric/stomach cancer | Covered | J9264, C16.0–C16.9 | Check plan-level benefit for chemotherapy step requirements |
| Biliary tract malignancies | Covered | J9264, C22.x–C24.x | Includes intrahepatic bile duct (C22.1), extrahepatic (C24.0), ampulla of Vater (C24.1) |
| Esophageal cancer | Covered | J9264, C15.3–C15.9 | Squamous cell histology codes covered |
| Small bowel adenocarcinoma | Covered | J9264, C17.0–C17.9 | Less common indication — verify prior auth language matches |
| Head and neck malignancies | Covered | J9264, C07, C11.x | Nasopharyngeal and parotid gland primaries included |
| Anal canal cancer | Covered | J9264, C21.0–C21.1 | Confirm combination regimen aligns with authorized treatment plan |
| Conventional paclitaxel substitution | Not Covered | J9267 vs. J9264 | Abraxane (J9264) and paclitaxel (J9267) are not interchangeable under this CPB |
| Off-label use outside covered ICD-10 list | Not Covered | J9264 | Claims will deny on medical necessity grounds |
Aetna Albumin-Bound Paclitaxel Billing Guidelines and Action Items 2025
The September 26, 2025 effective date is your hard deadline. Here's what to do before then.
| # | Action Item |
|---|---|
| 1 | Audit your J9264 charge capture against the updated ICD-10 list. Pull every active Abraxane case and confirm the diagnosis code maps to a covered ICD-10 sub-code under CPB 0834. Don't rely on header-level codes like C25 — Aetna looks at the full sub-code. |
| 2 | Confirm prior authorization covers the specific regimen and indication. If a patient's treatment plan changed after the original auth was granted, get a new authorization. Combination regimens using Abraxane with gemcitabine (J9201 or J9196), carboplatin (J9045), cisplatin (J9060), docetaxel (J9171 or J9172), or trastuzumab (J9355) each carry their own documentation requirements. |
| 3 | Separate your infusion administration coding from the drug code. Abraxane infusions bill under CPT 96413 (initial chemotherapy infusion) and 96415 (each additional hour). Concurrent infusions of other agents use 96416 or 96417. Sequential agents on the same day use 96367. Get your administration code selection right — mismatched administration codes and drug codes are a common denial trigger for high-cost chemo claims. |
| 4 | Do not swap J9267 for J9264 or vice versa without a new prior auth. These are different drugs under Aetna's policy. A provider switching from conventional paclitaxel to Abraxane needs the authorization updated before you submit the first J9264 claim. |
| 5 | Flag Medicare members out of this workflow. CPB 0834 applies to commercial plans only. If a patient has Medicare Advantage through Aetna, that's a different policy path. Route those cases through Aetna's Medicare Part B criteria instead. |
| 6 | Check plan-level benefit language for step therapy requirements. Some Aetna commercial plans require a trial of conventional paclitaxel before approving Abraxane. If your provider prescribes Abraxane as first-line and the plan has a step requirement, you'll need a step therapy exception before billing J9264. |
| 7 | Talk to your compliance officer if you have cases that sit on the edge of the covered ICD-10 list. With 411 codes in scope, there are still plenty of oncology diagnoses that fall outside this CPB. If you're uncertain whether a specific tumor type qualifies, get that determination in writing before the claim goes out. |
| Previous Version | Current Version |
|---|---|
| Coverage is considered experimental and investigational for all indications | Coverage is considered medically necessary when specific criteria are met |
| Prior authorization is not required | Prior authorization is required for initial treatment |
| Documentation must include clinical history | Documentation must include clinical history |
| Re-review every 24 months | Re-review every 12 months with updated clinical documentation |
CPT, HCPCS, and ICD-10 Codes for Albumin-Bound Paclitaxel Under CPB 0834
Covered HCPCS Code (When Selection Criteria Are Met)
| Code | Type | Description |
|---|---|---|
| J9264 | HCPCS | Injection, paclitaxel protein-bound particles, 1 mg (Abraxane) |
CPT Codes for Chemotherapy and Infusion Administration
| Code | Type | Description |
|---|---|---|
| 96365 | CPT | IV infusion, therapy/prophylaxis/diagnosis — initial |
| 96366 | CPT | IV infusion, therapy/prophylaxis/diagnosis — each additional hour |
| 96367 | CPT | IV infusion, therapy/prophylaxis/diagnosis — additional sequential infusion |
| 96368 | CPT | IV infusion, therapy/prophylaxis/diagnosis — concurrent infusion |
| 96413 | CPT | Chemotherapy administration, intravenous infusion — initial |
| 96414 | CPT | Chemotherapy administration, intravenous infusion — each additional hour |
| 96415 | CPT | Chemotherapy administration, intravenous infusion — each additional hour (sequential) |
| 96416 | CPT | Chemotherapy administration, initiation of prolonged infusion |
| 96417 | CPT | Chemotherapy administration, each additional sequential infusion, different drug |
Key ICD-10-CM Diagnosis Codes
The full covered list includes 411 codes. Below are the primary diagnosis groupings from the policy data.
| Code(s) | Description |
|---|---|
| C07 | Malignant neoplasm of parotid gland |
| C11.0–C11.9 | Malignant neoplasm of nasopharynx |
| C15.3–C15.9 | Malignant neoplasm of esophagus (squamous cell) |
| C16.0–C16.9 | Malignant neoplasm of stomach |
| C17.0–C17.9 | Malignant neoplasm of small intestine (small bowel adenocarcinoma) |
| C21.0–C21.1 | Malignant neoplasm of anus and anal canal |
| C22.0–C22.9 | Malignant neoplasm of liver and intrahepatic bile ducts |
| C22.1 | Intrahepatic bile duct carcinoma |
| C24.0 | Malignant neoplasm of extrahepatic bile duct |
| C24.1 | Malignant neoplasm of ampulla of Vater |
| C24.8–C24.9 | Malignant neoplasm of other/unspecified biliary tract |
| C25.0–C25.9 | Malignant neoplasm of pancreas |
The full policy covers 411 ICD-10-CM codes across a broad range of solid tumor diagnoses. Access the complete list at the Aetna CPB 0834 source policy.
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