Aetna modified CPB 0940 governing mogamulizumab-kpkc (Poteligeo) coverage, effective September 26, 2025. Here's what billing teams need to know.
Aetna, a CVS Health company, updated CPB 0940 — its clinical policy bulletin for mogamulizumab-kpkc (Poteligeo) — effective September 26, 2025. This Poteligeo billing update covers HCPCS J9204 and a suite of chemotherapy administration CPT codes (96413, 96415, 96416, 96417, 96422, 96423, 96425) used when infusing this agent. The policy applies to commercial medical plans only — if you're billing Medicare, Aetna routes those cases to a separate Part B step criteria document. The ICD-10 codes in scope span mycosis fungoides (C84.0–C84.9) and Sézary's syndrome (C84.10–C84.19), plus adult T-cell lymphoma/leukemia (C91.50–C91.52).
Quick-Reference Table
| Field | Detail |
|---|---|
| Payer | Aetna (commercial plans) |
| Policy | Mogamulizumab-kpkc (Poteligeo) — CPB 0940 |
| Policy Code | CPB 0940 |
| Change Type | Modified |
| Effective Date | September 26, 2025 |
| Impact Level | High — oncology and hematology infusion centers billing J9204 |
| Specialties Affected | Hematology/oncology, infusion therapy, dermatologic oncology |
| Key Action | Verify your medical necessity documentation and prior authorization status for all active J9204 claims before billing after September 26, 2025 |
Aetna Mogamulizumab-kpkc Coverage Criteria and Medical Necessity Requirements 2025
The Aetna mogamulizumab-kpkc coverage policy under CPB 0940 Aetna system applies exclusively to commercial plan members. Medicare beneficiaries have a separate pathway — don't apply this CPB to Part B claims.
Poteligeo is a CCR4-directed monoclonal antibody approved for relapsed or refractory mycosis fungoides (MF) and Sézary's syndrome (SS). These are the primary T-cell lymphomas driving the diagnosis codes in this policy. The ICD-10 coverage footprint includes C84.0 through C84.9 for mycosis fungoides variants and C84.10 through C84.19 for the full Sézary's syndrome code range — all site-specific subcategories included.
Adult T-cell lymphoma/leukemia (HTLV-1-associated) is also in scope under C91.50, C91.51, and C91.52. This is a smaller patient population, but the addition matters. Make sure your medical necessity documentation ties clearly to the applicable ICD-10 code before you submit.
Prior authorization is standard for specialty oncology biologics under most Aetna commercial plans. Assume prior auth is required for J9204 unless you've confirmed otherwise with the specific plan. Missing that step is the fastest route to a claim denial on an expensive drug — mogamulizumab-kpkc runs well over $10,000 per cycle at most facilities.
Medical necessity documentation should establish that the patient has relapsed or refractory disease after prior systemic therapy. That's the standard clinical bar FDA approval set. Aetna's coverage policy will track closely to that bar — your clinical notes need to reflect it explicitly, not just carry a diagnosis code.
Coverage Indications at a Glance
| Indication | Status | Relevant Codes | Notes |
|---|---|---|---|
| Mycosis fungoides | Covered (when criteria met) | C84.0–C84.9, J9204 | All MF site-specific subcategories in scope; prior auth expected |
| Sézary's syndrome | Covered (when criteria met) | C84.10–C84.19, J9204 | Full subcategory range included; medical necessity documentation required |
| Adult T-cell lymphoma/leukemia (HTLV-1-associated) | Covered (when criteria met) | C91.50–C91.52, J9204 | All three subcategories (unspecified, in remission, relapsed) in scope |
| Mogamulizumab-kpkc IV infusion — up to 1 hour | Covered (when J9204 criteria met) | CPT 96413 | Primary infusion code; use with J9204 |
| Each additional infusion hour | Covered (when criteria met) | CPT 96415 | Add-on to 96413; report per additional hour |
| Prolonged infusion initiation (>8 hours) | Covered (when criteria met) | CPT 96416 | Portable/implantable pump required |
| Sequential infusion, additional substance | Covered (when criteria met) | CPT 96417 | Different drug/substance in same encounter |
| Intra-arterial infusion — up to 1 hour | Covered (when criteria met) | CPT 96422 | Less common route for this agent |
| Intra-arterial infusion, additional hour | Covered (when criteria met) | CPT 96423 | Add-on to 96422 |
| Prolonged intra-arterial infusion (>8 hours) | Covered (when criteria met) | CPT 96425 | Portable/implantable pump required |
| Medicare Part B cases | Not governed by CPB 0940 | See Aetna Part B step criteria | Use Aetna's separate Medicare Part B pathway |
Aetna Mogamulizumab-kpkc Billing Guidelines and Action Items 2025
The real issue with Poteligeo billing isn't the drug code — J9204 is straightforward at 1 mg per unit. The complexity lives in the infusion administration codes and the diagnosis specificity. Here's what to do before and after the September 26, 2025 effective date.
| # | Action Item |
|---|---|
| 1 | Audit your active J9204 claims now. Pull any claims for mogamulizumab-kpkc billed under commercial Aetna plans. Check that each claim carries a covered ICD-10 from the C84.0–C84.9, C84.10–C84.19, or C91.50–C91.52 ranges. A claim with only a non-specific or mismatched code will deny. |
| 2 | Confirm prior authorization status before the September 26 effective date. If you have patients currently on Poteligeo therapy cycles, verify that existing prior authorizations remain valid under the updated policy. Call Aetna provider services or check your PA portal. Don't assume a pre-September 26 auth carries forward automatically. |
| 3 | Match your infusion administration code to the actual session. CPT 96413 covers the first hour of IV infusion. Add 96415 for each additional hour. If the session runs beyond eight hours with a portable pump, use 96416 instead. Get this wrong and you face a claim denial or a reimbursement shortfall — Aetna will not upcategorize a 96413 to 96416 on appeal. |
| 4 | Bill J9204 in units of 1 mg. The HCPCS descriptor is clear: one unit equals 1 mg of mogamulizumab-kpkc. Calculate your units from the actual administered dose, not the vial size. Document the administered dose in the clinical notes — Aetna can request records on high-cost biologics, and a dose mismatch between the chart and the claim is a compliance problem. |
| 5 | Separate Medicare and commercial claims completely. CPB 0940 does not govern Aetna Medicare Advantage or Part B billing. If your practice sees both commercial and Medicare Aetna members on Poteligeo, your billing team needs distinct workflows. Applying CPB 0940 criteria to a Medicare Advantage claim will create errors. Check Aetna's Part B step criteria document for those cases. |
| 6 | Update your charge capture for CPT 96422, 96423, and 96425. These intra-arterial codes appear in the policy, though they're rarely the primary route for mogamulizumab-kpkc. If your infusion center does use intra-arterial administration, make sure your charge capture reflects the correct codes. These are easy to miscapture under the more familiar IV codes. |
| 7 | Loop in your compliance officer if you're uncertain about the modified criteria. If your volume of Poteligeo cases is high or you've had prior denials on this drug, have your compliance officer review what changed between the previous version and the September 26, 2025 version. PayerPolicy's line-by-line version diff tool shows exactly what Aetna modified — use it before you assume nothing material changed. |
| 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 Mogamulizumab-kpkc (Poteligeo) Under CPB 0940
HCPCS Code — Mogamulizumab-kpkc Drug
| Code | Type | Description |
|---|---|---|
| J9204 | HCPCS | Injection, mogamulizumab-kpkc, 1 mg |
CPT Codes — Chemotherapy Administration
| Code | Type | Description |
|---|---|---|
| 96413 | CPT | Chemotherapy administration, intravenous infusion technique; up to 1 hour, single or initial substance |
| 96415 | CPT | Each additional hour (add-on to 96413) |
| 96416 | CPT | Initiation of prolonged chemotherapy infusion (more than 8 hours), requiring use of a portable or implantable pump |
| 96417 | CPT | Each additional sequential infusion (different substance/drug), up to 1 hour (add-on code) |
| 96422 | CPT | Chemotherapy administration, intra-arterial; infusion technique, up to 1 hour |
| 96423 | CPT | Chemotherapy administration, intra-arterial; each additional hour (add-on to 96422) |
| 96425 | CPT | Chemotherapy administration, intra-arterial; infusion technique, initiation of prolonged infusion (more than 8 hours), requiring use of a portable or implantable pump |
Key ICD-10-CM Diagnosis Codes
| Code | Description |
|---|---|
| C84.0 | Mycosis fungoides, unspecified site |
| C84.1 | Mycosis fungoides, lymph nodes of head, face, and neck |
| C84.2 | Mycosis fungoides, intrathoracic lymph nodes |
| C84.3 | Mycosis fungoides, intra-abdominal lymph nodes |
| C84.4 | Mycosis fungoides, lymph nodes of axilla and upper limb |
| C84.5 | Mycosis fungoides, lymph nodes of inguinal region and lower limb |
| C84.6 | Mycosis fungoides, intrapelvic lymph nodes |
| C84.7 | Mycosis fungoides, spleen |
| C84.8 | Mycosis fungoides, lymph nodes of multiple sites |
| C84.9 | Mycosis fungoides, extranodal and solid organ sites |
| C84.10 | Sézary's syndrome, unspecified site |
| C84.11 | Sézary's syndrome, lymph nodes of head, face, and neck |
| C84.12 | Sézary's syndrome, intrathoracic lymph nodes |
| C84.13 | Sézary's syndrome, intra-abdominal lymph nodes |
| C84.14 | Sézary's syndrome, lymph nodes of axilla and upper limb |
| C84.15 | Sézary's syndrome, lymph nodes of inguinal region and lower limb |
| C84.16 | Sézary's syndrome, intrapelvic lymph nodes |
| C84.17 | Sézary's syndrome, spleen |
| C84.18 | Sézary's syndrome, lymph nodes of multiple sites |
| C84.19 | Sézary's syndrome, extranodal and solid organ sites |
| C91.50 | Adult T-cell lymphoma/leukemia (HTLV-1-associated), unspecified |
| C91.51 | Adult T-cell lymphoma/leukemia (HTLV-1-associated), in remission |
| C91.52 | Adult T-cell lymphoma/leukemia (HTLV-1-associated), in relapse |
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