Aetna modified CPB 0874 for Radium Ra 223 Dichloride (Xofigo), effective January 5, 2026. Here's what billing teams need to act on now.
Aetna, a CVS Health company, updated Clinical Policy Bulletin CPB 0874 Aetna system, covering HCPCS code A9606 (Radium Ra-223 dichloride, therapeutic, per microcurie) for commercial plan members. The revised Aetna Radium Ra 223 Dichloride coverage policy now formally includes osteosarcoma as a covered indication alongside the existing castration-resistant prostate cancer criteria. If your oncology practice or infusion center bills A9606, this change directly affects how you document and precertify claims before submission.
Quick-Reference Table
| Field | Detail |
|---|---|
| Payer | Aetna, a CVS Health company |
| Policy | Radium Ra 223 Dichloride (Xofigo) — CPB 0874 |
| Policy Code | CPB 0874 |
| Change Type | Modified |
| Effective Date | January 5, 2026 |
| Impact Level | High |
| Specialties Affected | Medical Oncology, Radiation Oncology, Urology, Infusion Centers |
| Key Action | Confirm precertification is in place for A9606 and update clinical documentation templates to reflect the two covered indications and their specific criteria |
Aetna Radium Ra 223 Dichloride Coverage Criteria and Medical Necessity Requirements 2026
The coverage policy requires precertification for every patient, every time. Call (866) 752-7021 or fax your Statement of Medical Necessity to (888) 267-3277 before the first injection. There is no exception for known-covered patients.
Castration-Resistant Prostate Cancer
Aetna covers six injections of Xofigo (A9606) for bone metastases in castration-resistant prostate cancer. All three of the following criteria must be met — not two of three, all three.
First, the member must have symptomatic bone metastases. Asymptomatic bone involvement does not meet medical necessity under this policy. Document the symptom burden explicitly in your clinical notes.
Second, the member must have no visceral metastatic disease. Visceral mets are a hard stop. If your patient has liver, lung, or other visceral involvement, Aetna will not authorize Xofigo under this coverage policy. Don't submit and wait — confirm visceral status before precertification.
Third, the member must either have had a bilateral orchiectomy (CPT 54520, 54522, 54530, or 54535) or be on concurrent androgen deprivation therapy. Accepted ADT agents include LHRH agonists — goserelin (J9202), leuprolide (J9217, J9218, J9219) — or LHRH antagonists — degarelix (J9155) or relugolix. Relugolix has no specific HCPCS code in this policy, so document the drug name clearly in your precertification submission.
If you're billing for both the orchiectomy and Xofigo, report C61 (malignant neoplasm of prostate) alongside C79.51 (secondary malignant neoplasm of bone). Aetna flags this as a dual diagnosis requirement — missing C79.51 is a fast path to claim denial.
Osteosarcoma — New in This Update
This is the meaningful change in CPB 0874. Aetna now considers six injections of Xofigo medically necessary for subsequent treatment of osteosarcoma. The member must have tried at least two prior systemic therapies before Xofigo is considered.
Document the prior therapy lines clearly. List the regimens, dates, and reasons for discontinuation. Aetna will want to see this at precertification. Use ICD-10 codes from the C40.00–C41.9 range for malignant neoplasm of bone. The source policy does not specify a dual diagnosis requirement for osteosarcoma claims.
This is a real expansion of covered indications. Billing teams that treat osteosarcoma patients — often at academic centers and specialty cancer programs — should flag this for their oncology schedulers now.
Aetna Radium Ra 223 Dichloride Exclusions and Non-Covered Indications
Aetna is explicit: all indications outside prostate cancer and osteosarcoma are experimental, investigational, or unproven. That's a broad exclusion that covers a lot of off-label use.
Renal cell carcinoma, breast cancer, multiple myeloma, and medulloblastoma all appear in the ICD-10 code table associated with this policy — but not as covered indications. Those codes appear in the policy's broader code reference, not in the medical necessity criteria. Don't interpret their presence in the code table as coverage approval.
If a physician wants to use Xofigo for any of these diagnoses, the path runs through appeals and medical exception processes, not standard precertification. Talk to your compliance officer before submitting claims for off-label Xofigo use. The financial exposure and audit risk are real.
Coverage Indications at a Glance
| Indication | Status | Relevant Codes | Notes |
|---|---|---|---|
| Castration-resistant prostate cancer with symptomatic bone mets, no visceral disease, on ADT or post-bilateral orchiectomy | Covered — up to 6 injections | A9606, C61 + C79.51 (dual Dx required), J9202/J9217/J9218/J9219/J9155 for ADT | Prior authorization required. All three criteria must be met. |
| Osteosarcoma — subsequent treatment, ≥2 prior systemic therapies | Covered — up to 6 injections | A9606, C40.00–C41.9 | New indication in this update. Document prior therapy lines at precertification. No dual diagnosis requirement specified by source policy. |
| Renal cell carcinoma | Not Covered — Experimental | C64.1–C64.9 | ICD-10 codes appear in policy tables but are not covered indications. |
| Breast cancer | Not Covered — Experimental | C50.011–C50.A2 | Off-label. Not approved under CPB 0874. |
| Multiple myeloma | Not Covered — Experimental | C90.0–C90.2 | Off-label. Not approved under CPB 0874. |
| Medulloblastoma | Not Covered — Experimental | C71.6, C79.51 | Off-label. Not approved under CPB 0874. |
| All other indications | Not Covered — Experimental | — | Aetna considers all other uses unproven. |
Aetna Xofigo Billing Guidelines and Action Items 2026
The effective date is January 5, 2026. If you haven't already reviewed your workflow against this updated policy, do it now.
| # | Action Item |
|---|---|
| 1 | Update your precertification workflow for A9606 immediately. Every Xofigo claim requires prior authorization before the first injection. The precert line is (866) 752-7021. Add this to your infusion center's scheduling checklist so no patient reaches the chair without an active authorization. |
| 2 | Add osteosarcoma to your Xofigo clinical documentation templates. Your templates likely only covered prostate cancer before this update. Add a section capturing prior systemic therapy history — drug names, dates, and reason for discontinuation — for osteosarcoma patients. Without this, your precertification request will stall. |
| 3 | Enforce the dual diagnosis requirement for prostate cancer claims. Every prostate cancer claim for Xofigo reimbursement must carry both C61 and C79.51. Run a charge capture audit on any Xofigo claims submitted after January 5, 2026 to confirm this pairing is in place. A single-code submission will hit a claim denial. |
| 4 | Verify ADT status before precertification for prostate cancer patients. Confirm whether the patient has had a bilateral orchiectomy (and document the CPT code — 54520, 54522, 54530, or 54535) or is actively receiving ADT. If using relugolix, document by drug name since there's no specific HCPCS code assigned in this policy. This is a common precertification gap. |
| 5 | Flag visceral metastases as a hard exclusion in your clinical screening process. Build a visceral met check into your prostate cancer precertification workflow. If imaging shows visceral involvement, do not submit for Xofigo under this coverage policy. Alert the ordering physician to discuss alternative treatment options before a prior auth request is filed. |
| 6 | Audit any pending or recently denied Xofigo claims for osteosarcoma patients. If you have osteosarcoma patients who were denied Xofigo coverage before January 5, 2026, check whether they now meet the updated criteria. Submit a reconsideration with updated documentation of prior systemic therapy history. The new indication may open a path to Xofigo billing guidelines that wasn't available before. |
| 7 | Check your plan design list. Precertification applies to Aetna participating providers in applicable plan designs. Not every commercial plan design requires the same precert process. Confirm your specific plan contracts with your Aetna provider relations contact if you're unsure which plans apply. |
| 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 Radium Ra 223 Dichloride Under CPB 0874
HCPCS Codes Covered When Selection Criteria Are Met
| Code | Type | Description |
|---|---|---|
| A9606 | HCPCS | Radium Ra-223 dichloride, therapeutic, per microcurie |
Other HCPCS Codes Referenced in CPB 0874 Policy Table
The following HCPCS codes appear in the CPB 0874 policy code table. J9202, J9217, J9218, J9219, J9155, and J9217 are ADT agents that appear in the prostate cancer coverage criteria. J9041, J9046, J9048, J9049, J9051 (bortezomib variants), and J9171 (docetaxel) are also listed in the policy table but are not ADT agents and are not part of the Xofigo coverage criteria. Their presence in the policy table does not indicate a coverage relationship with A9606.
| Code | Type | Description |
|---|---|---|
| J9155 | HCPCS | Injection, degarelix, 1 mg |
| J9202 | HCPCS | Goserelin acetate implant, per 3.6 mg |
| J9217 | HCPCS | Leuprolide acetate (for depot suspension), 7.5 mg |
| J9218 | HCPCS | Leuprolide acetate, per 1 mg |
| J9219 | HCPCS | Leuprolide acetate implant, 65 mg |
| J9041 | HCPCS | Injection, bortezomib (Velcade), 0.1 mg |
| J9046 | HCPCS | Injection, bortezomib (Dr. Reddy's), not therapeutically equivalent to J9041, 0.1 mg |
| J9048 | HCPCS | Injection, bortezomib (Fresenius Kabi), not therapeutically equivalent to J9041, 0.1 mg |
| J9049 | HCPCS | Injection, bortezomib (Hospira), not therapeutically equivalent to J9041, 0.1 mg |
| J9051 | HCPCS | Injection, bortezomib (Maia), not therapeutically equivalent to J9041, 0.1 mg |
| J9171 | HCPCS | Injection, docetaxel, 1 mg |
CPT Codes Related to CPB 0874
| Code | Type | Description |
|---|---|---|
| 54520 | CPT | Orchiectomy, simple (including subcapsular), with or without testicular prosthesis, scrotal or inguinal approach |
| 54522 | CPT | Orchiectomy, partial |
| 54530 | CPT | Orchiectomy, radical, for tumor; inguinal approach |
| 54535 | CPT | Orchiectomy, radical, for tumor; with abdominal exploration |
| 96413 | CPT | Chemotherapy administration; intravenous infusion technique |
| 96414 | CPT | Chemotherapy administration; intravenous infusion technique |
| 96415 | CPT | Chemotherapy administration; intravenous infusion technique |
| 96416 | CPT | Chemotherapy administration; intravenous infusion technique |
| 96417 | CPT | Chemotherapy administration; intravenous infusion technique |
| 0600T | CPT | Ablation, irreversible electroporation; one or more tumors per organ, including imaging guidance |
| 0601T | CPT | Ablation, irreversible electroporation; one or more tumors, including fluoroscopic and ultrasound guidance |
Key ICD-10-CM Diagnosis Codes
| Code | Description | Coverage Status Under CPB 0874 |
|---|---|---|
| C61 | Malignant neoplasm of prostate | Covered — must be reported with C79.51 |
| C79.51 | Secondary malignant neoplasm of bone | Covered — required dual diagnosis for prostate cancer claims |
| C40.00–C41.9 | Malignant neoplasm of bone (osteosarcoma) | Covered — new indication in this update. No dual diagnosis requirement specified by source policy. |
| C50.011–C50.A2 | Malignant neoplasm of breast | Not covered — experimental/investigational |
| C64.1–C64.9 | Malignant neoplasm of kidney (renal cell carcinoma) | Not covered — experimental/investigational |
| C71.6 | Malignant neoplasm of cerebellum (medulloblastoma) | Not covered — experimental/investigational |
| C90.0–C90.2 | Multiple myeloma | Not covered — experimental/investigational |
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