Amivantamab-vmjw (Rybrevant) — CPB 0995 | AETNA Coverage Update

TL;DR: Aetna modified CPB 0995 for amivantamab-vmjw (Rybrevant), effective September 26, 2025. Billing teams need to confirm prior authorization is in place and that HCPCS J9061 claims are supported by EGFR mutation documentation before submitting.

Aetna, a CVS Health company, updated its amivantamab-vmjw coverage policy under CPB 0995 Aetna system, effective September 26, 2025. This bispecific antibody targets EGFR and MET mutations and is used primarily in non-small cell lung cancer (NSCLC). The core codes in play are HCPCS J9061 (amivantamab-vmjw, 2 mg per unit), CPT 81235 for EGFR gene analysis, and chemotherapy administration codes 96413–96417. If your practice bills oncology or infusion services for Aetna commercial members, this policy change belongs on your radar now.

Quick-Reference Table

Aetna Amivantamab-vmjw Coverage Criteria and Medical Necessity Requirements 2025

The Aetna amivantamab-vmjw coverage policy under CPB 0995 applies to commercial medical plan members only. Medicare criteria live separately — see Aetna's Medicare Part B step therapy page for those guidelines. Do not apply commercial CPB 0995 criteria to Medicare Advantage claims.

Precertification is required for every Aetna participating provider and member in applicable plan designs. No exceptions. You call (866) 752-7021 or fax (888) 267-3277 to initiate prior authorization. Statement of Medical Necessity (SMN) forms are available through Aetna's Specialty Pharmacy Precertification portal.

The medical necessity foundation for J9061 claims rests on confirmed EGFR mutation status. CPT 81235 — EGFR gene analysis for common variants in non-small cell lung cancer — is the molecular testing code tied to this drug's coverage logic. If you're submitting J9061 without documented EGFR mutation results in the medical record, expect a claim denial. That's not a guess; it's how Aetna's oncology medical necessity criteria consistently work for targeted therapies.

The ICD-10 code set supporting this policy is heavy on NSCLC (C34.x series, 112 codes total across the policy). Aetna also includes esophageal malignancies (C15.x) and gastric malignancies (C16.x) in the covered diagnosis set — worth knowing if your oncology practice treats upper GI cancers alongside thoracic cases. Map your diagnosis codes precisely. Submitting a C34.10 when the chart supports C34.11 won't cause a denial by itself, but sloppy ICD-10 specificity invites additional documentation requests.

Reimbursement for amivantamab-vmjw billing flows through the infusion administration codes alongside J9061. CPT 96413 covers the initial hour of chemotherapy infusion. CPT 96414 covers each additional sequential hour of a different drug. CPT 96415 covers additional hours of the same drug. CPT 96416 covers initiation of a prolonged infusion (more than eight hours) requiring a pump. CPT 96417 covers each additional sequential drug infusion over 15 minutes. Your charge capture needs to reflect the actual infusion sequence — Aetna's coverage policy does not give you latitude to default to a single code.

Aetna Amivantamab-vmjw Exclusions and Non-Covered Indications

The policy data flags a specific subset of HCPCS codes under a separate coverage group label tied to lazertinib, osimertinib (Tagrisso), and combination regimens. Codes J9045 (carboplatin), J9060 (cisplatin), J9263 (oxaliplatin), and the full pemetrexed family (J9294, J9296, J9297, J9305, J9314, J9322, J9323, J9324) fall under that group label — "no specific criteria met" is the language in the policy data.

The real issue here: these platinum and pemetrexed codes represent the chemotherapy backbone used in combination regimens with amivantamab. Aetna separates them from J9061 in the coverage groupings. This does not mean they are universally denied, but it does mean they do not automatically ride J9061's coverage approval. If your practice bills combination regimens, verify that the precertification request covers the full regimen — not just the amivantamab component.

Osimertinib (Tagrisso) and lazertinib claims for Aetna commercial members are governed by a different policy framework. Do not assume CPB 0995 approval covers those agents. Billing them together under one auth without confirming scope is how you generate a split claim denial three months later.

Coverage Indications at a Glance

Aetna Amivantamab-vmjw Billing Guidelines and Action Items 2025

CPT, HCPCS, and ICD-10 Codes for Amivantamab-vmjw Under CPB 0995

Covered HCPCS Code (When Selection Criteria Are Met)

HCPCS Codes — Combination Regimen Agents (No Specific Criteria Listed)

CPT Codes Related to CPB 0995

Key ICD-10-CM Diagnosis Codes

The full ICD-10-CM list contains 112 codes. The C34.x series covers the complete NSCLC laterality and lobe specificity set. Use the most specific code supported by the medical record.