Pertuzumab (Perjeta) — CPB 0973 | AETNA Coverage Update

Aetna modified CPB 0973 for pertuzumab (Perjeta), effective September 26, 2025. Here's what billing teams need to do.

Aetna, a CVS Health company, updated its pertuzumab (Perjeta) coverage policy under CPB 0973 on September 26, 2025. This policy governs HCPCS code J9306 (injection, pertuzumab, 1 mg) and the chemotherapy administration codes CPT 96413–96417. If your team bills J9306 for HER2-positive breast cancer or gastric/gastroesophageal junction adenocarcinoma patients on commercial Aetna plans, this update deserves your attention before claims go out the door.

Quick-Reference Table

Aetna Pertuzumab Coverage Criteria and Medical Necessity Requirements 2025

The Aetna pertuzumab coverage policy under CPB 0973 applies to commercial medical plans only. Medicare patients follow separate Part B criteria — do not use this CPB as your medical necessity guide for Medicare-covered patients.

Precertification is mandatory. Every Aetna participating provider and member in an applicable plan design must get prior authorization before administering pertuzumab. There are no exceptions for urgent infusions on commercial plans — if the precertification isn't in place, the claim denial risk is yours.

To get prior authorization, call (866) 752-7021 or fax (888) 267-3277. For Statement of Medical Necessity forms, use the Specialty Pharmacy Precertification portal on Aetna's provider site. Build these numbers into your precertification workflow now — before September 26, 2025.

The real issue here is site of care. Aetna's Site of Care Utilization Management Policy applies to pertuzumab, which means Aetna will review where the infusion happens — not just whether it's medically necessary. Infusions approved for hospital outpatient settings may face a reimbursement challenge if a lower-cost site is deemed appropriate. This is the same site-of-care pressure Aetna has been applying to other specialty drug infusions, and it's now explicitly called out in CPB 0973.

Check Aetna's Utilization Management Policy on Site of Care for Specialty Drug Infusions before you schedule infusions in higher-cost settings. If you're running a hospital outpatient infusion center and billing CPT 96413–96417 alongside J9306, document why that site is clinically appropriate. Put it in the chart before the infusion, not after the denial.

Coverage Indications at a Glance

The policy summary does not enumerate individual covered indications with explicit approval/denial breakdowns — those details live in the full CPB 0973 document, which requires login access. What the policy does make clear is the structure: J9306 is the covered code when selection criteria are met, and precertification is the gate. The ICD-10 codes listed below represent the diagnosis codes tied to this policy, spanning HER2-positive cancers across multiple tumor sites.

Aetna Pertuzumab Billing Guidelines and Action Items 2025

This is where the CPB 0973 Aetna system change gets concrete for your billing team. These aren't suggestions — act on them before claims go out after September 26, 2025.

If you're unsure how the site-of-care policy applies to your specific infusion setting mix, talk to your compliance officer before September 26, 2025. The financial exposure on high-cost oncology drugs like pertuzumab is too large to guess.

CPT, HCPCS, and ICD-10 Codes for Pertuzumab Under CPB 0973

HCPCS Codes — Covered When Selection Criteria Are Met

HCPCS Codes — Related to CPB 0973

CPT Codes — Chemotherapy Administration

Key ICD-10-CM Diagnosis Codes

This policy references 184 ICD-10-CM codes. Below is the complete set from the policy data provided.

The full policy references 184 ICD-10-CM codes. The table above reflects the complete set provided in the policy data. Access the full code list at app.payerpolicy.org/p/aetna/0973.