Inotuzumab Ozogamicin (Besponsa) — CPB 0919 | AETNA Coverage Update

Aetna modified CPB 0919 for inotuzumab ozogamicin (Besponsa), effective January 29, 2026. Here's what billing teams need to know.

Aetna, a CVS Health company, updated its inotuzumab ozogamicin coverage policy under CPB 0919 to expand frontline treatment criteria for acute lymphoblastic leukemia (ALL) and lymphoblastic lymphoma. The primary billing code is J9229 (injection, inotuzumab ozogamicin, 0.1 mg), administered with chemotherapy administration codes in the 96365–96450 range. This change affects oncology and hematology practices billing Aetna commercial plans — and the criteria are specific enough that missing one checkbox will cost you a clean claim.

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Quick-Reference Table

Field	Detail Copy
Payer	Aetna, a CVS Health company
Policy	Inotuzumab Ozogamicin (Besponsa) — CPB 0919
Policy Code	CPB 0919
Change Type	Modified
Effective Date	January 29, 2026
Impact Level	High
Specialties Affected	Hematology, Medical Oncology, Infusion Centers
Key Action	Update prior authorization requests to include CD22-positive confirmation, Philadelphia chromosome status, and planned combination regimen before billing J9229

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Aetna Inotuzumab Ozogamicin Coverage Criteria and Medical Necessity Requirements 2026

The Aetna inotuzumab ozogamicin coverage policy divides approval into two distinct clinical scenarios: frontline therapy and relapsed/refractory disease. Both require prior authorization. Call (866) 752-7021 or fax (888) 267-3277 to precertify — don't wait until after the first infusion.

Frontline (Induction/Consolidation) Therapy — All five criteria must be met:

This is the more restrictive path. Philadelphia chromosome-positive patients don't qualify for frontline coverage under this policy. That's a hard stop — document Ph status in the medical record before you submit.

Relapsed or Refractory Disease — All five criteria must be met:

The six-cycle cap applies to both paths. Aetna won't approve beyond that under any circumstances listed in this policy.

Continuation of Therapy requires reauthorization. Aetna approves continuation when there's no evidence of unacceptable toxicity or disease progression. That means your reauthorization documentation needs to show treatment response — not just that the patient is still on therapy.

Prior authorization is required for all Aetna participating providers and members in applicable plan designs. Submit a Statement of Medical Necessity (SMN) form available at Aetna's Specialty Pharmacy Precertification page. Missing or incomplete documentation is the fastest path to a claim denial.

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Aetna Inotuzumab Ozogamicin Exclusions and Non-Covered Indications

Aetna considers all indications outside of ALL and lymphoblastic lymphoma to be experimental, investigational, or unproven. This is a blanket exclusion. If your treatment team is exploring Besponsa for any off-label use outside these specific diagnoses — follicular lymphoma, diffuse large B-cell lymphoma, or anything else — Aetna won't cover it under this coverage policy.

The ICD-10 code list in this policy does include follicular lymphoma codes (C82.x series), but those appear in the broader code set associated with the policy, not as approved indications. Don't let a code appearing in the policy file make you think it's covered. The clinical criteria are what control approval.

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Coverage Indications at a Glance

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Aetna Inotuzumab Ozogamicin Billing Guidelines and Action Items 2026

Inotuzumab ozogamicin billing under CPB 0919 has enough moving parts that a checklist approach pays off. Here's what your team needs to do before January 29, 2026 — and at every authorization cycle after.

Copy Action Items

If your patient population has an unusual mix of Ph-positive frontline cases or off-label requests, talk to your compliance officer before the effective date. The coverage policy draws sharp lines, and edge cases here carry real financial exposure.

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CPT, HCPCS, and ICD-10 Codes for Inotuzumab Ozogamicin Under CPB 0919

Key HCPCS Codes

Chemotherapy Administration CPT Codes

These codes cover administration of inotuzumab ozogamicin and combination chemotherapy agents. Bill the appropriate code based on route, drug, and administration time.

Code	Type	Description Copy
96365	CPT	IV infusion, therapy/prophylaxis/diagnosis — initial
96366	CPT	IV infusion — each additional hour
96401–96450	CPT	Chemotherapy administration (full range)

Note: The policy lists CPT codes 96401 through 96450 as related codes. Select the specific code that matches the administration method and sequence for each drug in the regimen.

Key ICD-10-CM Diagnosis Codes

The following codes appear in the CPB 0919 policy. Coverage is driven by the clinical criteria above — confirm each patient's diagnosis maps to an approved indication before billing J9229.

The full ICD-10 code set in CPB 0919 includes 145 codes. The complete list is available at the Aetna CPB 0919 source page. Verify that your primary diagnosis code maps to an ALL or lymphoblastic lymphoma indication — not just that it appears in the broader code set.

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