Aetna modified CPB 0955 for polatuzumab vedotin-piiq (Polivy), effective September 26, 2025. Here's what changes for billing teams.
Aetna, a CVS Health company, updated its coverage policy for polatuzumab vedotin-piiq (Polivy) under CPB 0955 in the CPB 0955 Aetna system. The update expands and refines medical necessity criteria across multiple B-cell lymphoma subtypes. If your team bills J9309 for Polivy infusions — or submits claims using CPT 96413 and 96415 for the infusion administration — this policy affects your prior authorization workflow starting September 26, 2025.
Quick-Reference Table
| Field | Detail |
|---|---|
| Payer | Aetna, a CVS Health company |
| Policy | Polatuzumab vedotin-piiq (Polivy) — CPB 0955 |
| Policy Code | CPB 0955 |
| Change Type | Modified |
| Effective Date | September 26, 2025 |
| Impact Level | High |
| Specialties Affected | Hematology/Oncology, Infusion Centers, Hospital Outpatient |
| Key Action | Update prior authorization workflows for J9309 to reflect new indication-specific criteria before September 26, 2025 |
Aetna Polatuzumab Vedotin Coverage Criteria and Medical Necessity Requirements 2025
The core of this Aetna polatuzumab vedotin coverage policy is a detailed, subtype-by-subtype breakdown of when Polivy is — and isn't — medically necessary. Aetna approves up to six cycles. The approved indication, combination regimen, line of therapy, and transplant eligibility all determine whether a claim clears prior authorization.
Diffuse Large B-Cell Lymphoma (DLBCL)
DLBCL is the broadest indication. Aetna considers J9309 medically necessary for DLBCL under three distinct scenarios.
First: subsequent treatment as a single agent or in combination with bendamustine (J9033, J9034, J9036, J9056, J9058, or J9059) and/or rituximab (J9312, J9311, or biosimilar Q5115) for relapsed or refractory disease when the member is not a candidate for transplant, or when Polivy serves as a bridge until a CAR T-cell product is available.
Second: subsequent treatment in combination with mosunetuzumab-axgb (J9350) for relapsed or refractory disease.
Third — and this is the first-line pathway — in combination with R-CHP (rituximab product, cyclophosphamide [J8530, J9071–J9076], doxorubicin [J9000], and prednisone [J7512]) when the member has an International Prognostic Index (IPI) score greater than 1. Get that IPI score documented in the precertification record. Without it, expect a claim denial.
High-Grade B-Cell Lymphomas (HGBL) — "Double-Hit" and "Triple-Hit"
HGBLs follow a similar three-path structure to DLBCL, with one important difference at the first-line level. Aetna covers first-line R-CHP only when the member has an IPI score greater than 1 AND has MYC and BCL6 rearrangements without BCL2 rearrangement.
That molecular qualifier is a denial trap. If the biomarker documentation isn't in the precertification package, the claim won't survive. Work with your clinical team to confirm BCL2 rearrangement status is explicitly addressed in the supporting documentation.
HIV-Related B-Cell Lymphomas
This category covers HIV-related DLBCL, primary effusion lymphoma, HIV-related plasmablastic lymphoma, and HHV8-positive DLBCL. Aetna covers Polivy in two scenarios: subsequent treatment as a single agent or with bendamustine and/or rituximab when the member is not a candidate for transplant or needs a CAR T bridge, or subsequent treatment in combination with mosunetuzumab-axgb for relapsed/refractory disease. There is no first-line R-CHP pathway for this subtype. Don't submit one without checking updated criteria first.
Histologic Transformation of Indolent Lymphomas to DLBCL
This subtype gets two pathways: subsequent treatment (single agent or with bendamustine/rituximab) when the member is not a transplant candidate, or first-line R-CHP when the IPI score is 2 or greater. That IPI threshold differs from DLBCL (greater than 1 vs. 2 or greater). Map the right threshold to the right diagnosis code before you submit.
Precertification 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 (SMN) forms, use the Specialty Pharmacy Precertification portal at Aetna's provider forms page. Build this into your workflow before the first infusion is scheduled — not after.
Aetna Polatuzumab Vedotin Exclusions and Non-Covered Indications
The policy summary provided does not enumerate a standalone experimental/investigational section for Polivy. However, coverage is strictly criteria-driven. Any use outside the approved subtype-and-regimen combinations listed above is effectively not covered. Polivy as first-line monotherapy, or in combinations not listed (for example, first-line use in HIV-related subtypes), does not meet medical necessity under this policy. Submitting outside those boundaries without additional documentation is a fast path to denial.
Coverage Indications at a Glance
| Indication | Status | Key Codes | Notes |
|---|---|---|---|
| DLBCL — subsequent therapy (single agent or + bendamustine/rituximab), relapsed/refractory, transplant-ineligible or CAR T bridge | Covered | J9309, J9033–J9059, J9311–J9312, Q5115 | Up to 6 cycles; prior auth required |
| DLBCL — subsequent therapy + mosunetuzumab-axgb, relapsed/refractory | Covered | J9309, J9350 | Up to 6 cycles; prior auth required |
| DLBCL — first-line R-CHP, IPI score > 1 | Covered | J9309, J9312, J9000, J7512, J8530/J9071–J9076 | IPI score must be documented |
| HGBL ("double-hit"/"triple-hit") — subsequent therapy (single agent or + bendamustine/rituximab), transplant-ineligible or CAR T bridge | Covered | J9309, J9033–J9059, J9311–J9312, Q5115 | Up to 6 cycles; prior auth required |
| HGBL — subsequent therapy + mosunetuzumab-axgb, relapsed/refractory | Covered | J9309, J9350 | Up to 6 cycles; prior auth required |
| HGBL — first-line R-CHP, IPI > 1 + MYC/BCL6 without BCL2 rearrangement | Covered | J9309, J9312, J9000, J7512, J8530/J9071–J9076 | Biomarker documentation required |
| HIV-related B-cell lymphomas — subsequent therapy (single agent or + bendamustine/rituximab), transplant-ineligible or CAR T bridge | Covered | J9309, J9033–J9059, J9311–J9312, Q5115 | Up to 6 cycles; prior auth required |
| HIV-related B-cell lymphomas — subsequent therapy + mosunetuzumab-axgb, relapsed/refractory | Covered | J9309, J9350 | Up to 6 cycles; prior auth required |
| HIV-related B-cell lymphomas — first-line R-CHP | Not Covered / Not Listed | — | No first-line pathway for this subtype |
| Histologic transformation of indolent lymphomas to DLBCL — subsequent therapy (single agent or + bendamustine/rituximab), transplant-ineligible | Covered | J9309, J9033–J9059, J9311–J9312, Q5115 | Up to 6 cycles; prior auth required |
| Histologic transformation of indolent lymphomas to DLBCL — first-line R-CHP, IPI ≥ 2 | Covered | J9309, J9312, J9000, J7512, J8530/J9071–J9076 | IPI threshold is ≥ 2, not > 1 |
Aetna Polatuzumab Vedotin Billing Guidelines and Action Items 2025
This is the highest-financial-exposure part of the policy. Polivy infusions bill at J9309 per 1 mg. These aren't low-dollar claims. One missed documentation requirement — a missing IPI score, an undocumented biomarker, a wrong transplant eligibility notation — kills a five- or six-figure authorization.
| # | Action Item |
|---|---|
| 1 | Audit your PA template before September 26, 2025. Your prior authorization forms for J9309 must capture: lymphoma subtype, line of therapy, combination regimen, transplant candidacy, IPI score, and (for HGBL first-line) MYC/BCL6/BCL2 rearrangement status. If any of those fields are missing from your current template, fix them now. |
| 2 | Map your ICD-10 codes to the right IPI threshold. DLBCL and HGBL first-line use requires IPI > 1. Histologic transformation first-line use requires IPI ≥ 2. These are different thresholds. Code the diagnosis correctly and match it to the documented IPI score before submission. |
| 3 | Update charge capture for all R-CHP component codes. When Polivy is billed as part of R-CHP, your charge capture should consistently include J9309 alongside J9312 (or J9311 or Q5115 for the rituximab component), J9000 or Q2050 for doxorubicin, J8530 or the appropriate J9071–J9076 code for cyclophosphamide, and J7512 for prednisone. Inconsistent component billing is a common audit trigger. |
| 4 | Confirm infusion administration codes match the session. CPT 96413 covers the first hour of IV chemotherapy infusion. CPT 96415 covers each additional hour. If Polivy and a combination agent are administered in the same session, confirm your charge capture correctly sequences the primary and subsequent infusion codes. |
| 5 | For CAR T-eligible members using Polivy as a bridge, document the bridge rationale explicitly. Aetna covers bridging use pending CAR T availability. That's not a blank check — you need documentation showing CAR T is the intended definitive therapy and that Polivy is temporary. CPT codes 38225–38228 (CAR T harvest, preparation, transport, and administration) are referenced in this coverage policy, which tells you Aetna expects to see the full CAR T episode tracked on these members. |
| 6 | Talk to your compliance officer if your practice treats HIV-related lymphoma subtypes. The HIV-related criteria are narrower than DLBCL. First-line R-CHP is not covered for that subtype under this policy. If you have patients in that population where first-line Polivy is being considered, confirm your reimbursement strategy before September 26, 2025. |
| 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 Polatuzumab Vedotin Under CPB 0955
Covered HCPCS Code (When Selection Criteria Are Met)
| Code | Type | Description |
|---|---|---|
| J9309 | HCPCS | Injection, polatuzumab vedotin-piiq, 1 mg |
Key ICD-10-CM Diagnosis Codes
| Code | Description |
|---|---|
| C82.0–C82.19 | Follicular lymphoma, grade I (various sites) |
| C82.20–C82.29 | Follicular lymphoma, grade II (various sites) |
| C82.30–C82.39 | Follicular lymphoma, grade III (various sites) |
| C82.40–C82.49 | Follicular lymphoma, grade IIIa (various sites) |
| C82.50–C82.59 | Follicular lymphoma, grade IIIb (various sites) |
The full ICD-10-CM code list under CPB 0955 includes 144 codes spanning follicular lymphoma subtypes (C82.x series) and additional B-cell lymphoma diagnoses. Review the complete list at the Aetna CPB 0955 policy page before finalizing your ICD-10 mapping.
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