Aetna modified CPB 0993 covering dostarlimab-gxly (Jemperli) for multiple solid tumor indications, effective January 29, 2026. Here's what billing teams need to do.
Aetna, a CVS Health company, updated its dostarlimab-gxly coverage policy under CPB 0993 Aetna system on January 29, 2026. The policy now covers Jemperli across a significantly expanded list of tumor types—including breast cancer, colorectal cancer, esophageal and gastric cancers, and dMMR solid tumors—all billed through HCPCS J9272 (injection, dostarlimab-gxly, 10 mg). If your oncology billing team hasn't reviewed this policy since last year, this update touches more indications than most checkpoint inhibitor policies do.
Quick-Reference Table
| Field | Detail |
|---|---|
| Payer | Aetna, a CVS Health company |
| Policy | Dostarlimab-gxly (Jemperli) — CPB 0993 |
| Policy Code | CPB 0993 |
| Change Type | Modified |
| Effective Date | January 29, 2026 |
| Impact Level | High |
| Specialties Affected | Oncology, Hematology/Oncology, Gynecologic Oncology, GI Oncology |
| Key Action | Confirm MSI-H/dMMR biomarker documentation is in the chart before submitting precertification for J9272 |
Aetna Dostarlimab-gxly Coverage Criteria and Medical Necessity Requirements 2026
The Aetna dostarlimab-gxly coverage policy under CPB 0993 requires precertification for all participating providers and members in applicable commercial plan designs. This is not optional. Call (866) 752-7021 or fax (888) 267-3277 to precertify. Statement of Medical Necessity forms are on the Aetna Specialty Pharmacy Precertification page.
The site of care utilization management policy also applies. Aetna's Site of Care for Specialty Drug Infusions policy controls where Jemperli can be administered for reimbursement. If your practice is billing infusion at a hospital outpatient department when an alternative infusion site is available, expect scrutiny.
Medical necessity for J9272 hinges almost entirely on two things: tumor biomarker status and prior treatment history. Every covered indication below requires either microsatellite instability-high (MSI-H) or mismatch repair deficient (dMMR) tumor status—or in one case, POLE/POLD1 ultra-hypermutated phenotype. If that molecular pathology isn't documented in the chart, prior authorization will be denied. Make that documentation pull a standard part of your precertification workflow.
Here's how medical necessity breaks down across the six main covered indications:
Ampullary Adenocarcinoma: Jemperli is covered as a single agent for recurrent or advanced MSI-H or dMMR disease that progressed on prior treatment, with no satisfactory alternative treatment options.
Endometrial Carcinoma: Two covered scenarios. First, single-agent use for recurrent or advanced MSI-H or dMMR endometrial cancer that progressed on a platinum-containing regimen. Second, combination use with carboplatin (J9045) and paclitaxel (J9267) for up to six cycles of combination therapy, followed by Jemperli monotherapy, in members with stage III–IV or recurrent disease. The combination indication does not require MSI-H or dMMR status—that's a critical distinction your billing team needs to track.
dMMR Solid Tumors: Single-agent coverage for any dMMR solid tumor with recurrent or advanced disease that progressed on prior treatment, when no satisfactory alternatives exist. This is a broad tumor-agnostic bucket—useful when the primary tumor type doesn't fit a named category.
Breast Cancer: This is the most restrictive indication. The member must have MSI-H or dMMR breast cancer, with no response to preoperative systemic therapy, recurrent unresectable or stage IV (M1) disease that progressed on prior treatment, and no satisfactory alternatives. On top of that, line-of-therapy thresholds apply: third-line or later for HER2-negative disease, and fourth-line or later for HER2-positive disease. Document HER2 status and treatment history clearly—this one has multiple gatekeeping criteria.
Colorectal Cancer: Covered for MSI-H, dMMR, or POLE/POLD1 ultra-hypermutated phenotype (tumor mutational burden greater than 50 mut/Mb). This explicitly includes appendiceal adenocarcinoma and anal adenocarcinoma. The POLE/POLD1 pathway is notable—it opens coverage for a subset of colorectal patients who are MSS but have extreme hypermutation.
Esophageal, Esophagogastric Junction, and Gastric Cancer: Covered for dMMR recurrent or advanced disease. The policy lists esophagectomy CPT codes (43107, 43108, 43112, 43113, 43116, 43117, 43118, 43121, 43122, 43123, 43124, 43286, 43287, 43288) as related codes—these appear in the context of surgical procedures for the same tumor types, not as coverage requirements for the drug itself.
Aetna Dostarlimab-gxly Exclusions and Non-Covered Indications
There's one clean exclusion in this policy: members who experienced disease progression while on PD-1 or PD-L1 inhibitor therapy are not eligible for Jemperli. Full stop.
This matters because dostarlimab-gxly is itself a PD-1 inhibitor. Aetna is saying that if a patient already progressed through another checkpoint inhibitor in the same class—pembrolizumab, nivolumab, cemiplimab, and others—this drug won't be covered as a subsequent line. That's a meaningful population exclusion in a space where oncologists sometimes try sequential PD-1 blockade.
Document prior immunotherapy exposure in the precertification request. If the prior auth doesn't address this point directly, Aetna's reviewers will ask.
Coverage Indications at a Glance
| Indication | Status | Key Biomarker Requirement | Line of Therapy | Notes |
|---|---|---|---|---|
| Ampullary Adenocarcinoma | Covered | MSI-H or dMMR | Subsequent (post prior treatment) | No satisfactory alternative required |
| Endometrial Carcinoma — Single Agent | Covered | MSI-H or dMMR | Post platinum-containing regimen | Recurrent or advanced only |
| Endometrial Carcinoma — Combination | Covered | None specified | First-line for stage III–IV or recurrent | With carboplatin + paclitaxel ×6, then mono |
| dMMR Solid Tumors (tumor-agnostic) | Covered | dMMR | Post prior treatment | No satisfactory alternative required |
| Breast Cancer — HER2-negative | Covered | MSI-H or dMMR | Third-line or later | Stage IV or recurrent unresectable; no preop response |
| Breast Cancer — HER2-positive | Covered | MSI-H or dMMR | Fourth-line or later | Stage IV or recurrent unresectable; no preop response |
| Colorectal, Appendiceal, Anal Adenocarcinoma | Covered | MSI-H, dMMR, or POLE/POLD1 (TMB >50 mut/Mb) | Not specified | Explicit inclusion of appendiceal and anal subtypes |
| Esophageal / EGJ / Gastric Cancer | Covered | dMMR | Recurrent or advanced | Related esophagectomy CPTs listed in policy |
| Post-PD-1/PD-L1 progression | Not Covered | N/A | N/A | Global exclusion regardless of indication |
Aetna Dostarlimab-gxly Billing Guidelines and Action Items 2026
The effective date of January 29, 2026 means this policy is live now. If your team hasn't adjusted workflows since this update, you're already behind.
| # | Action Item |
|---|---|
| 1 | Add biomarker documentation to your precertification checklist immediately. Every covered indication except the endometrial carcinoma combination requires MSI-H, dMMR, or POLE/POLD1 testing results. Pull the molecular pathology report before you call (866) 752-7021. Missing biomarker data is the fastest path to a claim denial. |
| 2 | Flag the endometrial combination regimen as a separate clinical scenario. When billing carboplatin (J9045) plus paclitaxel (J9267) plus J9272 for endometrial carcinoma, document that this is combination therapy and the cycle count. Aetna covers up to six combination doses—after cycle six, the authorization needs to shift to Jemperli monotherapy. Treat these as two distinct authorization periods. |
| 3 | Screen for prior PD-1/PD-L1 exposure before submitting. Build a treatment history check into your prior authorization intake. If a patient received pembrolizumab, nivolumab, or any other checkpoint inhibitor and progressed, Aetna will deny the claim. Catch this before it becomes a denial to work. |
| 4 | Review your site-of-care setup for J9272. Aetna's Site of Care Utilization Management Policy applies to Jemperli infusions. If you're billing infusion at a higher-cost setting when a lower-cost alternative is available, Aetna may redirect or deny. Confirm your infusion site is acceptable under the current policy before scheduling. If you're uncertain how this applies to your mix, talk to your compliance officer before submitting. |
| 5 | For colorectal cancer cases, confirm POLE/POLD1 and TMB reporting. The policy covers colorectal tumors with POLE/POLD1 ultra-hypermutated phenotype when tumor mutational burden exceeds 50 mut/Mb. This is a less common but valid pathway. Make sure your pathology reports include TMB quantification—"ultra-hypermutated" as a qualitative descriptor alone may not be enough for prior auth documentation. |
| 6 | Update your breast cancer criteria checklist. Dostarlimab-gxly billing for breast cancer requires several simultaneous conditions: correct disease stage, no preoperative response, progression on prior treatment, correct HER2 status, and correct line of therapy. Build a documentation checklist specific to this indication. A single missing element triggers denial. |
| 7 | Track authorization renewal timing for monotherapy continuation. After initial coverage periods, Aetna will require renewal authorization. Set calendar reminders tied to each patient's authorization start date. Late renewals create billing gaps that are hard to recover after the fact. |
| 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 Dostarlimab-gxly Under CPB 0993
Covered HCPCS Codes (When Selection Criteria Are Met)
| Code | Type | Description |
|---|---|---|
| J9272 | HCPCS | Injection, dostarlimab-gxly, 10 mg |
CPT Codes Related to This Policy
| Code | Type | Description |
|---|---|---|
| 96413 | CPT | Chemotherapy administration, intravenous infusion technique; up to 1 hour |
| 96414 | CPT | Chemotherapy administration, intravenous infusion; each additional hour |
| 96415 | CPT | Chemotherapy administration, intravenous infusion; each additional hour (sequential) |
| 96416 | CPT | Chemotherapy administration, intravenous infusion; initiation of prolonged infusion |
| 96417 | CPT | Chemotherapy administration, intravenous infusion; each additional sequential infusion |
| 43107 | CPT | Total or near total esophagectomy, without thoracotomy; with pharyngogastrostomy or cervical esophagogastrostomy |
| 43108 | CPT | Total or near total esophagectomy, without thoracotomy; with colon interposition or small intestine reconstruction |
| 43112 | CPT | Total or near total esophagectomy, with thoracotomy; with pharyngogastrostomy or cervical esophagogastrostomy |
| 43113 | CPT | Total or near total esophagectomy, with thoracotomy; with colon interposition or small intestine reconstruction |
| 43116 | CPT | Partial esophagectomy, cervical, with free intestinal graft, including microvascular anastomosis |
| 43117 | CPT | Partial esophagectomy, distal two-thirds, with thoracotomy and separate abdominal incision |
| 43118 | CPT | Partial esophagectomy, distal two-thirds, with thoracotomy; with colon interposition or small intestine reconstruction |
| 43121 | CPT | Partial esophagectomy, distal two-thirds, with thoracotomy only, with or without proximal gastrectomy |
| 43122 | CPT | Partial esophagectomy, thoracoabdominal or abdominal approach, with or without proximal gastrectomy |
| 43123 | CPT | Partial esophagectomy, thoracoabdominal approach; with colon interposition or small intestine reconstruction |
| 43124 | CPT | Total or partial esophagectomy, without reconstruction (any approach), with cervical esophagostomy |
| 43286 | CPT | Esophagectomy, total or near total, with laparoscopic mobilization of the abdominal and mediastinal esophagus |
| 43287 | CPT | Esophagectomy, distal two-thirds, with laparoscopic mobilization of the abdominal and lower mediastinal esophagus |
| 43288 | CPT | Esophagectomy, total or near total, with thoracoscopic mobilization of the upper, middle, and lower mediastinal esophagus |
Key ICD-10-CM Diagnosis Codes
The full policy includes 658 ICD-10-CM codes. The table below lists the primary categories represented. Confirm the complete code list in CPB 0993 at the Aetna provider portal before submitting claims.
| Code | Description |
|---|---|
| C11.0–C11.9 | Malignant neoplasm of nasopharynx (dMMR recurrent or advanced) |
| C12 | Malignant neoplasm of pyriform sinus (dMMR recurrent or advanced) |
| C13.0–C13.9 | Malignant neoplasm of hypopharynx (dMMR recurrent or advanced) |
| C14.0–C14.8 | Malignant neoplasm of other/ill-defined sites, lip, oral cavity, pharynx (dMMR recurrent or advanced) |
| C15.3–C15.9 | Malignant neoplasm of esophagus (dMMR recurrent or advanced) |
| C16.0–C16.8 | Malignant neoplasm of stomach (dMMR recurrent or advanced) |
With 658 total ICD-10 codes spanning nasopharyngeal, esophageal, gastric, colorectal, endometrial, breast, and other solid tumor types, this policy has one of the broader diagnosis code footprints in oncology. Pull the full list from CPB 0993 directly and cross-reference against your EHR's charge capture to make sure every covered tumor type maps correctly.
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