Durvalumab (Imfinzi) — CPB 0917 | AETNA Coverage Update

Aetna modified CPB 0917 for durvalumab (Imfinzi), effective December 6, 2025. Here's what billing teams need to do.

Aetna, a CVS Health company, updated its durvalumab (Imfinzi) coverage policy under CPB 0917 on December 6, 2025. This policy governs reimbursement for J9173 (injection, durvalumab, 10 mg) across a wide range of oncology indications—from lung cancer to biliary tract cancer to head and neck squamous cell carcinoma. If your practice bills J9173 alongside chemotherapy administration codes 96413 through 96417, this update affects your prior authorization workflow and medical necessity documentation immediately.

---

Quick-Reference Table

Field	Detail Copy
Payer	Aetna, a CVS Health company
Policy	Durvalumab (Imfinzi) — CPB 0917
Policy Code	CPB 0917
Change Type	Modified
Effective Date	December 6, 2025
Impact Level	High
Specialties Affected	Medical oncology, hematology/oncology, thoracic surgery, hepatobiliary surgery, head and neck surgery
Key Action	Audit all active durvalumab prior authorizations against updated indication-level criteria before billing J9173 on or after December 6, 2025

---

Aetna Durvalumab Coverage Criteria and Medical Necessity Requirements 2025

The Aetna durvalumab coverage policy under CPB 0917 is one of the more layered oncology policies you'll see. The indication list is long, and the biomarker requirements are specific. Getting this wrong means claim denial—and with a drug that costs well over $10,000 per infusion cycle, the financial exposure is real.

Precertification is required for all Aetna participating providers and members in applicable plan designs. Call (866) 752-7021 or fax (888) 267-3277 to initiate prior authorization. You can also access Statement of Medical Necessity forms at Aetna's Specialty Pharmacy Precertification portal.

Aetna also applies a Site of Care Utilization Management policy to durvalumab. Before you bill 96413 for the infusion, confirm that the site of service meets Aetna's requirements under their Drug Infusion Site of Care policy. This is separate from the clinical coverage criteria—and a denial on site of service grounds is just as costly as a denial on medical necessity grounds.

Non-Small Cell Lung Cancer (NSCLC)

Aetna covers durvalumab for NSCLC under three distinct clinical scenarios. Each has its own biomarker and treatment context requirements.

Unresectable Stage II or III NSCLC: The member must have disease that has not progressed following concurrent platinum-based chemoradiation. The tumor must be negative for EGFR exon 19 deletion and exon 21 L858R mutations—verified by CPT 81235. Durvalumab is covered as a single agent only in this setting.

Recurrent, Advanced, or Metastatic NSCLC: The tumor must be negative for EGFR exon 19 deletion, exon 21 L858R mutations, and ALK, RET, and ROS1 rearrangements. Coverage applies when durvalumab is used in combination with tremelimumab-actl (J9347) and platinum-based chemotherapy, or as maintenance therapy—either as a single agent or in combination with pemetrexed (J9304 or J9305).

Resectable NSCLC: Coverage requires neoadjuvant treatment combined with platinum-containing chemotherapy, followed by adjuvant single-agent durvalumab after surgery. The same biomarker exclusions apply: negative for EGFR exon 19 deletion, exon 21 L858R mutations, ALK, RET, and ROS1 rearrangements.

The pattern here is clear—EGFR-mutated NSCLC is excluded across all three NSCLC indications. Make sure your team pulls the molecular testing results before submitting any prior auth for lung cancer patients.

Small Cell Lung Cancer (SCLC)

The SCLC coverage criteria in CPB 0917 are newer and worth close attention. Aetna covers durvalumab in three SCLC scenarios:

#	Covered Indication Copy
1	First-line treatment of extensive-stage SCLC in combination with etoposide (J9181) and carboplatin (J9045) or cisplatin (J9060), followed by single-agent maintenance
2	Adjuvant consolidation for limited-stage SCLC as a single agent, when the member did not progress after systemic therapy with concurrent radiation
3	Subsequent therapy for progression or relapse, in combination with etoposide and carboplatin or cisplatin, followed by single-agent maintenance

The adjuvant consolidation indication for limited-stage SCLC is the one to flag. It's a narrower population with a specific treatment history requirement. Document the prior systemic therapy and radiation course clearly in your prior auth submission.

Biliary Tract Cancer

Aetna covers durvalumab for biliary tract cancer in combination with cisplatin (J9060) or carboplatin (J9045) and gemcitabine (J9201, J9196, J9198, or J9184). This applies to locally advanced, unresectable, gross residual (R2) disease, and metastatic biliary tract cancer. The policy also covers adjuvant treatment in this setting and covers resectable locoregionally advanced gallbladder cancer when combined with cisplatin or carboplatin and gemcitabine.

These are meaningful expansions relative to earlier Imfinzi policies. If your practice treats biliary tract cancers, audit your charge capture for J9173 now.

---

Aetna Durvalumab Exclusions and Non-Covered Indications

The primary exclusion under CPB 0917 is straightforward: Aetna does not cover durvalumab for members who experienced disease progression while on PD-1 or PD-L1 inhibitor therapy.

This exclusion matters because durvalumab itself is a PD-L1 inhibitor. A patient who progressed on pembrolizumab (J9271), nivolumab (J9299), atezolizumab (J9022), avelumab (J9023), or cemiplimab (J9119) is not eligible for Imfinzi under this policy. The inclusion of those codes in the CPB is directly relevant here—they're the agents that create ineligibility.

Document prior immunotherapy exposure in every prior auth submission. A claim denial because of undisclosed prior PD-L1 progression is hard to appeal and harder to explain to the oncologist.

EGFR-mutated NSCLC is functionally excluded from all NSCLC indications. Aetna will not approve durvalumab for a patient with EGFR exon 19 deletion or exon 21 L858R mutation in the lung cancer setting. The CPT 81235 result needs to be in the chart and referenced in the auth request.

---

Coverage Indications at a Glance

---

Aetna Durvalumab Billing Guidelines and Action Items 2025

These are not general suggestions. The effective date is December 6, 2025—if you bill J9173 for Aetna members and haven't done these things, do them now.

Copy Action Items

If you're unsure how this policy applies to your specific patient mix or payer contract, talk to your compliance officer before December 6, 2025.

---

CPT, HCPCS, and ICD-10 Codes for Durvalumab Under CPB 0917

Covered HCPCS Codes (When Selection Criteria Are Met)

Code	Type	Description Copy
J9173	HCPCS	Injection, durvalumab, 10 mg

Other HCPCS Codes Related to CPB 0917

These codes appear in the policy as related agents—combination therapies, comparators, and agents that may create ineligibility.

CPT Codes Related to CPB 0917

Key ICD-10-CM Diagnosis Codes

The full policy includes 351 ICD-10-CM codes. The table below shows a representative sample of the primary diagnosis categories. Your billing team should pull the complete code list from CPB 0917 directly for claim-level code selection.

With 351 ICD-10-CM codes in scope, don't rely on memory or prior claim templates. Pull the full list from the Aetna CPB 0917 source document and validate diagnosis codes at the claim level.

---