TL;DR: Aetna, a CVS Health company, modified CPB 0898 covering necitumumab (Portrazza) for metastatic squamous NSCLC, effective February 25, 2026. Billing teams need to confirm combination regimen documentation before submitting J9295 claims.
Aetna's updated necitumumab coverage policy under CPB 0898 locks approval to one specific use: metastatic squamous non-small cell lung cancer (NSCLC) billed with HCPCS J9295 (necitumumab injection), administered alongside gemcitabine (J9201 or biosimilar equivalents) and cisplatin (J9060). The effective date of February 25, 2026 is already live. If your oncology billing team hasn't reviewed claims going out the door, you're already at risk.
Quick-Reference Table
| Field | Detail |
|---|---|
| Payer | Aetna |
| Policy | Necitumumab (Portrazza) — CPB 0898 |
| Policy Code | CPB 0898 |
| Change Type | Modified |
| Effective Date | February 25, 2026 |
| Impact Level | Medium |
| Specialties Affected | Medical Oncology, Hematology/Oncology, Infusion Centers |
| Key Action | Confirm all J9295 claims include documented combination use with gemcitabine and cisplatin before submission |
Aetna Necitumumab Coverage Criteria and Medical Necessity Requirements 2026
Aetna's necitumumab coverage policy is narrow by design. There is exactly one covered indication: metastatic squamous NSCLC, and only when necitumumab is used in combination with gemcitabine and cisplatin.
That combination requirement is the hard gate. Necitumumab used as monotherapy — or paired with any other regimen — does not meet medical necessity under this policy. Aetna considers any other use experimental, investigational, or unproven.
The covered HCPCS code for the drug itself is J9295 (injection, necitumumab, 1 mg). The companion drugs — cisplatin at J9060 and gemcitabine at J9201 — need to appear on the claim as well. Aetna's code table also lists two gemcitabine biosimilar codes: J9184 (gemcitabine hydrochloride, Avyxa formulation, 200 mg) and J9196 (gemcitabine hydrochloride, Accord formulation, 200 mg). These are treated as the non-therapeutically-equivalent alternative to J9201, so confirm which formulation your facility actually administers before you code.
The infusion administration codes — CPT 96413, 96414, 96415, and 96416 — are the vehicle for the chemotherapy delivery itself. These codes appear in the policy as related CPT codes, all described as chemotherapy administration, intravenous infusion technique. Your charge capture needs to reflect the correct sequencing based on the actual session — but the policy does not assign specific procedural roles to each code, so work with your coding team to apply them correctly to the services rendered.
CPB 0898 does not address prior authorization requirements for J9295. Verify PA requirements directly with Aetna before the first administration.
Aetna Necitumumab Exclusions and Non-Covered Indications
Aetna draws a hard line here. Everything outside metastatic squamous NSCLC in combination with gemcitabine and cisplatin is classified as experimental, investigational, or unproven.
This means non-squamous NSCLC is not covered. Small cell lung cancer is not covered. Off-label use in other solid tumors — colorectal, head and neck, or anything else — is not covered, regardless of clinical rationale.
The ICD-10 code list in CPB 0898 includes C19 (malignant neoplasm of rectosigmoid junction). Its presence in the code table is a flag, not an invitation. Aetna's criteria do not support necitumumab reimbursement for colorectal cancer. If your team sees C19 appear on a claim for J9295, that's a claim denial waiting to happen. The only ICD-10 codes that support a covered claim are the C34.xx codes for bronchus and lung malignancies mapped to metastatic squamous NSCLC.
J9271 (pembrolizumab) also appears in the code table. Pembrolizumab is listed as a related code, not a covered code under this CPB. Don't confuse its presence in the table with coverage for combination regimens that include pembrolizumab alongside necitumumab.
Coverage Indications at a Glance
| Indication | Status | Relevant Codes | Notes |
|---|---|---|---|
| Metastatic squamous NSCLC — combination with gemcitabine + cisplatin | Covered | J9295, J9060, J9201 (or J9184/J9196), C34.xx | All three agents must be part of the regimen |
| Metastatic squamous NSCLC — necitumumab monotherapy | Not Covered | J9295 | Combination requirement is absolute |
| Non-squamous NSCLC | Experimental/Investigational | J9295 | Outside approved indication |
| Small cell lung cancer | Experimental/Investigational | J9295 | Not addressed in covered criteria |
| Colorectal cancer (C19) | Experimental/Investigational | J9295 | ICD-10 appears in table but not in covered criteria |
| Any other indication | Experimental/Investigational | J9295 | Policy language is all-or-nothing |
| Continuation of therapy (covered indication) | Covered | J9295 | Requires no evidence of unacceptable toxicity or disease progression |
Aetna Necitumumab Billing Guidelines and Action Items 2026
This policy is already live as of February 25, 2026. Here's what your billing team needs to do now.
| # | Action Item |
|---|---|
| 1 | Audit open and pending J9295 claims immediately. Pull every claim with J9295 submitted on or after February 25, 2026 and verify that J9060 and J9201 (or J9184/J9196) appear on the same claim. A J9295 claim without the combination partners is a near-certain denial. |
| 2 | Confirm the gemcitabine formulation your facility uses. Aetna lists three gemcitabine codes: J9201 (standard), J9184 (Avyxa), and J9196 (Accord). Aetna specifically flags J9196 as not therapeutically equivalent to J9201. Code to the actual product administered — don't default to J9201 if your pharmacy stocks Accord. |
| 3 | Verify prior authorization requirements directly with Aetna. CPB 0898 does not address prior authorization. That doesn't mean PA isn't required — it means the CPB text doesn't tell you either way. Call Aetna's oncology line to confirm PA requirements before your first infusion claim goes out. This is general best practice for any high-cost specialty drug, not a requirement stated in this policy. |
| 4 | Map your ICD-10 codes carefully for C34.xx. The policy covers metastatic squamous NSCLC. Your diagnosis code must reflect metastatic and squamous histology. A C34.xx code alone isn't enough — the clinical documentation must support the squamous and metastatic descriptors. Work with your coding team and the treating oncologist to confirm the right specificity. |
| 5 | Set a documentation trigger for continuation of therapy claims. Aetna will cover continued necitumumab use only when there's no evidence of unacceptable toxicity or disease progression. For every continuation claim, pull the most recent oncology note confirming ongoing response and tolerability. Don't submit a continuation claim without that documentation attached or available on request. |
| 6 | Do not bill J9295 against non-squamous, colorectal, or other off-label diagnoses. The C19 code appearing in Aetna's table will tempt some billers into thinking it's covered. It isn't. If your oncologists are using necitumumab off-label, talk to your compliance officer before submitting those claims. The financial exposure from repeated denials — and potential recoupment — outweighs whatever reimbursement you're chasing. |
| 7 | Update your charge capture templates to link J9295 with the required companion codes. Build a rule in your EHR or charge capture tool that flags any J9295 charge entered without J9060 and a gemcitabine code. This catches the problem before the claim leaves your system, not after the denial lands. |
| 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 Necitumumab (Portrazza) Under CPB 0898
Covered HCPCS Code (When Selection Criteria Are Met)
| Code | Type | Description |
|---|---|---|
| J9295 | HCPCS | Injection, necitumumab, 1 mg |
Key ICD-10-CM Diagnosis Codes
The full ICD-10 list in CPB 0898 contains 95 codes. The C34.xx series covers malignant neoplasm of bronchus and lung mapped to metastatic squamous NSCLC — these are the codes that support covered claims. C19 appears in the table but does not meet the covered indication criteria. For the complete ICD-10 list across all 95 codes, review the full CPB 0898 document directly on Aetna's provider portal.
| Code | Description |
|---|---|
| C34.xx | Malignant neoplasm of bronchus and lung (metastatic squamous NSCLC) — full subcategory range included in CPB 0898; see full policy document for complete code list |
| C19 | Malignant neoplasm of rectosigmoid junction — present in table, NOT a covered indication under CPB 0898 |
Get the Full Picture for CPT 96413
Track this policy across versions, search 1,500+ policies by CPT code, and get real-time alerts when any payer changes coverage.