Polatuzumab vedotin-piiq (Polivy) — CPB 0955 | AETNA Coverage Update

Aetna modified CPB 0955 for polatuzumab vedotin-piiq (Polivy), effective September 26, 2025. Here's what billing teams need to know before that date.

Aetna, a CVS Health company, updated its Polivy coverage policy under CPB 0955 in the Aetna polatuzumab vedotin-piiq coverage policy governing commercial medical plans. The primary billing code is HCPCS J9309 (injection, polatuzumab vedotin-piiq, 1 mg), and precertification is required across all applicable plan designs. If your oncology or hematology billing team handles DLBCL or follicular lymphoma claims, this policy directly affects your authorization workflow and your exposure to claim denial.

Quick-Reference Table

Aetna Polatuzumab Vedotin-Piiq Coverage Criteria and Medical Necessity Requirements 2025

The single covered HCPCS code under this policy is J9309. Every claim for polatuzumab vedotin-piiq billing must clear precertification before administration. No exceptions exist for commercial plan members under participating provider agreements.

Aetna requires precertification for all participating providers and members in applicable plan designs. Call (866) 752-7021 or fax a Statement of Medical Necessity form to (888) 267-3277. Download the SMN precertification form at Aetna's Specialty Pharmacy Precertification page.

Medical necessity criteria are central to this coverage policy. The policy sits within the broader CPB 0955 Aetna system framework, which means Aetna's clinical reviewers will evaluate whether the diagnosis codes you submit—drawn from the 144 ICD-10-CM codes mapped to this policy—align with the approved indications for Polivy. The dominant diagnosis groups are diffuse large B-cell lymphoma (DLBCL) and follicular lymphoma, coded primarily under the C83 and C82 blocks respectively.

Polivy's FDA-approved indications include previously untreated DLBCL combined with R-CHP (rituximab, cyclophosphamide, doxorubicin, and prednisone) and relapsed/refractory DLBCL combined with bendamustine and rituximab (BR). The companion codes in this policy reflect both regimens. You'll see multiple J-codes for bendamustine (J9033, J9034, J9036, J9056, J9058, J9059), cyclophosphamide (J9071 through J9076, plus J8530 oral), rituximab (J9312, J9311, Q5115), and doxorubicin (J9000, Q2049, Q2050). These aren't incidental—Aetna maps them to this CPB because they appear alongside J9309 in covered regimens.

Prior authorization ties directly to medical necessity here. Without an active auth tied to the correct ICD-10 and regimen, your J9309 claim will deny. Period.

Reimbursement for polatuzumab vedotin-piiq on commercial plans flows through the medical benefit, not pharmacy. Administer and bill under CPT 96413 (IV infusion, up to one hour) and CPT 96415 (each additional hour) alongside J9309 for the drug itself.

For Medicare patients, this CPB does not apply. Aetna directs you to the Medicare Part B criteria separately. If your panel mixes commercial and Medicare Advantage patients, confirm which policy governs each claim before submitting.

Coverage Indications at a Glance

Aetna Polatuzumab Vedotin-Piiq Billing Guidelines and Action Items 2025

These are direct steps your billing and authorization team should complete before September 26, 2025.

1. Audit every active Polivy patient for precertification status before September 26, 2025.
Pull all accounts with J9309 on your charge capture. Verify each has an active Aetna precertification tied to the correct ICD-10 code. Any gap is a denial waiting to happen.

2. Use J9309 as the primary drug code—and only J9309.
This is the sole HCPCS code designated as covered when selection criteria are met. Don't bill a miscellaneous J-code. Aetna's system expects J9309 specifically, and substituting another code will trigger a review or denial.

3. Match companion agent J-codes to the actual product administered.
Bendamustine has six active J-codes in this policy—J9033 (Treanda), J9034 (Bendeka), J9036 (Belrapzo/bendamustine), J9056 (Vivimusta), J9058 (Apotex), J9059 (Baxter). Bill the code that matches the manufacturer of the product you actually gave. An NDC mismatch or wrong J-code here creates a separate denial risk.

4. Bill infusion administration correctly alongside J9309.
CPT 96413 covers the first hour of IV chemotherapy infusion. CPT 96415 covers each additional hour. Both appear in this policy as related codes. If your team is only billing the drug and not capturing the administration, you're leaving reimbursement on the table.

5. Submit the right ICD-10-CM code from the 144 mapped to this policy.
The policy includes 144 diagnosis codes across follicular lymphoma (C82 block) and large B-cell lymphoma (C83 block) categories. Submitting a diagnosis code outside this set—even if clinically accurate—will likely trigger a medical necessity denial. Map to the most specific subcategory code that matches the patient's pathology report.

6. Precertify through the correct channel.
Phone: (866) 752-7021. Fax: (888) 267-3277. Use the SMN form from Aetna's Specialty Pharmacy Precertification page. Don't assume a prior auth from another payer or a prior plan year carries over.

7. Separate Medicare Advantage patients from commercial patients.
CPB 0955 governs commercial plans only. Aetna Medicare Advantage patients follow separate Part B criteria. If you're billing Aetna MA plans under CPB 0955 criteria, your authorizations and coverage determinations may be wrong. Flag this for your compliance officer before the effective date.

CPT, HCPCS, and ICD-10 Codes for Polatuzumab Vedotin-Piiq Under CPB 0955

Primary Covered HCPCS Code

Key ICD-10-CM Diagnosis Codes

The full policy maps 144 ICD-10-CM codes. Below are the primary categories. Confirm the specific subcategory code against the patient's pathology report before submitting.

Note: The full ICD-10-CM code list under CPB 0955 contains 144 codes. Access the complete list at the Aetna CPB 0955 policy page.