Radium Ra 223 Dichloride (Xofigo) — CPB 0874 | AETNA Coverage Update

Aetna modified CPB 0874 covering Radium Ra 223 Dichloride (Xofigo), effective January 5, 2026. Here's what billing teams need to know before submitting claims.

Aetna, a CVS Health company, updated its Xofigo coverage policy under CPB 0874 Aetna system, adding osteosarcoma as a covered indication alongside the existing castration-resistant prostate cancer criteria. The primary billing code affected is HCPCS A9606 (Radium Ra-223 dichloride, therapeutic, per microcurie). If your team bills for oncology infusions — particularly in urology or orthopedic oncology — this change directly affects your prior authorization workflow and medical necessity documentation.

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Quick-Reference Table

Field	Detail Copy
Payer	Aetna
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	Urology, Medical Oncology, Orthopedic Oncology, Nuclear Medicine
Key Action	Update prior authorization workflows and medical necessity documentation for both prostate cancer and osteosarcoma indications before submitting new claims

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Aetna Xofigo Coverage Criteria and Medical Necessity Requirements 2026

The Aetna Xofigo coverage policy under CPB 0874 covers a total of six injections of Radium Ra 223 Dichloride. Two separate clinical populations can now qualify. Getting the criteria right at the front end is the only way to avoid a claim denial.

Castration-Resistant Prostate Cancer

For prostate cancer, Aetna considers Xofigo medically necessary when all three of the following criteria are met:

#	Covered Indication Copy
1	The member has symptomatic bone metastases
2	The member does not have visceral metastatic disease
3	The member has had a bilateral orchiectomy or will use Xofigo in combination with an LHRH agonist (goserelin, leuprolide) or antagonist (degarelix, relugolix)

All three criteria must be documented. Missing any one of them will trigger a denial. The visceral metastasis exclusion is a hard stop — if your patient has liver, lung, or other visceral disease, Aetna will not cover Xofigo under this policy regardless of bone involvement.

The androgen deprivation therapy (ADT) requirement is where billing teams often get tripped up. Document the specific agent your patient is receiving. Relevant HCPCS codes for ADT agents include J9155 (degarelix), J9202 (goserelin acetate implant), J9217 and J9218 (leuprolide acetate), and J9219 (leuprolide acetate implant). Relugolix has no dedicated HCPCS code in this policy — the grouped codes J9041 through J9051 are listed as placeholders, but none map directly to relugolix. Flag this with your compliance officer before billing.

For ICD-10 coding, prostate cancer requires a dual diagnosis: report C61 (malignant neoplasm of prostate) together with C79.51 (secondary malignant neoplasm of bone). Submitting C61 alone will not satisfy the diagnostic requirement. Build that pairing into your charge capture now.

Osteosarcoma — New in This Revision

This is the significant addition in the January 5, 2026 update. Aetna now considers Xofigo medically necessary for osteosarcoma as a subsequent-line treatment when the member has previously tried at least two systemic therapies.

The criteria here are simpler than for prostate cancer. There is no visceral metastasis exclusion and no ADT requirement. The single gate is prior systemic therapy — the member must have failed at least two lines of treatment. Document those prior therapies clearly in your prior authorization submission. Osteosarcoma maps to ICD-10 range C40.00–C41.9 (malignant neoplasm of bone).

Prior Authorization Requirements

Precertification is required for all Aetna participating providers and members in applicable plan designs. Call (866) 752-7021 or fax (888) 267-3277. For Statement of Medical Necessity forms, use the Specialty Pharmacy Precertification resources on Aetna's provider portal.

There is no workaround here. Submit prior authorization before the first injection. Six injections are covered when criteria are met — but your auth needs to reflect the full course.

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Aetna Xofigo Exclusions and Non-Covered Indications

Aetna considers all indications other than castration-resistant prostate cancer with bone metastases and osteosarcoma to be experimental, investigational, or unproven.

The ICD-10 table in this policy lists codes for breast cancer (C50.011–C50.A2), renal cell carcinoma (C64.1–C64.9), medulloblastoma (C71.6), and multiple myeloma (C90.0–C90.2). Those codes appear in the policy's code set, but they are not covered indications. Do not submit A9606 claims against those diagnoses expecting coverage. Claims will deny, and repeated submissions may trigger a medical necessity audit.

The real issue here is that having a code in a policy table does not mean the procedure is covered under that code. Your billing team needs to understand the distinction between "codes referenced in the policy" and "codes covered by the policy."

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Coverage Indications at a Glance

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Aetna Xofigo Billing Guidelines and Action Items 2026

The effective date is January 5, 2026. If you have pending authorizations or active Xofigo cases, review them against the updated criteria now.

Copy Action Items

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CPT, HCPCS, and ICD-10 Codes for Xofigo Under CPB 0874

HCPCS Codes — Primary Billing Code

Code	Description	Coverage Status Copy
A9606	Radium Ra-223 dichloride, therapeutic, per microcurie	Covered when selection criteria are met

HCPCS Codes — ADT Agents (Referenced in Criteria)

CPT Codes — Infusion Administration and Related Procedures

Key ICD-10-CM Diagnosis Codes

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