Summary: Aetna, a CVS Health company, modified CPB 0995 covering amivantamab-vmjw (Rybrevant), effective April 23, 2026. Here's what billing teams need to do.
Aetna updated its amivantamab-vmjw coverage policy under CPB 0995 Aetna system, and if your practice bills for this bispecific antibody in non-small cell lung cancer, this change deserves your attention before claims start dropping. The policy does not list specific CPT or HCPCS codes in the available data — but amivantamab-vmjw billing typically runs through J-code pathways for chemotherapy and biologic agents, so watch for code-level guidance in Aetna's full policy document. The effective date of April 23, 2026 makes this an immediate concern for oncology billing teams.
| Field | Detail |
|---|---|
| Payer | Aetna, a CVS Health company |
| Policy | Amivantamab-vmjw (Rybrevant) — CPB 0995 |
| Policy Code | CPB 0995 |
| Change Type | Modified |
| Effective Date | April 23, 2026 |
| Impact Level | High |
| Specialties Affected | Oncology, Hematology-Oncology, Thoracic Surgery, Infusion Centers |
| Key Action | Review Aetna's full CPB 0995 document for updated medical necessity criteria and prior authorization requirements before submitting claims dated on or after April 23, 2026 |
Aetna Amivantamab-vmjw Coverage Criteria and Medical Necessity Requirements 2026
Amivantamab-vmjw is a bispecific EGFR-MET antibody approved by the FDA for adult patients with locally advanced or metastatic non-small cell lung cancer (NSCLC). It targets two oncogenic drivers simultaneously — EGFR exon 20 insertion mutations and MET — which means the approved indications are specific and the documentation requirements are tight.
Aetna's coverage policy for Rybrevant under CPB 0995 governs whether claims for this drug are reimbursed or denied. Because the full modified policy text is not reproduced in the available data here, the specific revised medical necessity criteria are not quoted directly in this post. Pull the current CPB 0995 document directly from Aetna's clinical policy bulletin library or via the PayerPolicy source link at app.payerpolicy.org/p/aetna/0995 to see exactly what changed.
What we do know from Rybrevant's clinical context: medical necessity for amivantamab-vmjw historically hinges on confirmed EGFR exon 20 insertion mutation status, prior platinum-based chemotherapy, and appropriate line-of-therapy documentation. Aetna's coverage policy has also addressed the subcutaneous formulation (amivantamab-vmjw-rybp, approved by FDA in 2024) separately from the IV formulation — so confirm which formulation your claims cover and whether CPB 0995's updated criteria treat them differently.
Prior authorization is standard for Rybrevant under Aetna. That won't change with this modification. What may change are the specific clinical criteria Aetna requires to grant that authorization — mutation testing documentation, prior treatment lines, ECOG performance status thresholds, or combination therapy restrictions. If you're submitting prior auth requests dated on or after April 23, 2026, use the updated criteria, not the previous version.
Reimbursement for amivantamab-vmjw is tied to correct J-code submission, accurate diagnosis coding, and a clean prior auth chain. Any gap in that chain — wrong ICD-10, missing mutation documentation, outdated criteria — creates claim denial risk. This modification heightens that risk until your team has digested exactly what changed.
Aetna Amivantamab-vmjw Exclusions and Non-Covered Indications
The available policy data does not reproduce the specific exclusions from CPB 0995's modified version. That said, based on the established coverage pattern for bispecific antibodies in oncology, Aetna's coverage policy has historically excluded the following — and these categories are worth watching in the updated document:
Use outside confirmed mutation status. Rybrevant's mechanism is mutation-specific. Claims without documented EGFR exon 20 insertion mutation testing draw denials. Aetna requires molecular pathology evidence, not just clinical suspicion.
Off-label indications. Amivantamab-vmjw has an active clinical trial pipeline in other NSCLC subgroups and combination regimens. Aetna's coverage policy almost certainly limits reimbursement to FDA-approved indications and possibly specific NCCN-supported uses. Off-label billing without explicit policy support is a denial waiting to happen.
Combination regimens not specifically addressed. The PAPILLON trial established amivantamab plus lazertinib as a first-line option. If CPB 0995's modification addresses this combination — approving it, restricting it, or adding criteria — that's one of the most financially significant updates your billing team needs to find in the full document.
Check the updated CPB 0995 text directly. If you're not sure how your patient mix maps to the new criteria, loop in your compliance officer before submitting claims under the updated policy.
Coverage Indications at a Glance
The full modified CPB 0995 policy text is not available in the source data provided. The table below reflects the known FDA-approved and clinically established indications for amivantamab-vmjw as context — not as a substitute for Aetna's actual policy language. Verify each row against the live CPB 0995 document before using this for billing decisions.
| Indication | Status | Relevant Codes | Notes |
|---|---|---|---|
| Metastatic NSCLC with EGFR exon 20 insertion mutation, post-platinum chemotherapy (IV formulation) | Likely Covered — verify in CPB 0995 | Confirm J-code; EGFR mutation ICD-10 required | Core FDA-approved indication; prior auth required |
| Metastatic NSCLC with EGFR exon 20 insertion mutation, post-platinum chemotherapy (subcutaneous formulation) | Verify in CPB 0995 | Confirm J-code for SubQ formulation separately | Subcutaneous formulation approved FDA 2024; may have separate policy treatment |
| First-line NSCLC with EGFR exon 20 insertion mutation in combination with lazertinib | Verify in CPB 0995 | Confirm J-codes for both agents | PAPILLON trial data; check if CPB 0995 modification addresses this combination |
| Off-label or investigational uses | Likely Not Covered | N/A | Aetna standard exclusion for off-label use without NCCN support |
This table is a framework, not a final answer. Pull CPB 0995 directly and map each indication against Aetna's actual language.
Aetna Amivantamab-vmjw Billing Guidelines and Action Items 2026
Here's what your billing team should do right now.
| # | Action Item |
|---|---|
| 1 | Pull the full CPB 0995 document today. Go to app.payerpolicy.org/p/aetna/0995 or Aetna's clinical policy bulletin library. Read the modified version against the prior version line by line. The effective date of April 23, 2026 has passed — claims already may be processing under the updated criteria. |
| 2 | Confirm your J-code assignment for both Rybrevant formulations. The IV formulation and the subcutaneous formulation may carry different J-codes. Amivantamab-vmjw billing requires the correct HCPCS J-code for each. Submitting the wrong code — even if the drug is covered — triggers a claim denial. If you bill both formulations, audit your charge capture now. |
| 3 | Audit your prior authorization workflow against the updated criteria. Prior authorization requirements for Rybrevant under Aetna have always been strict. If CPB 0995's modification changed the clinical criteria for approval — mutation documentation requirements, line-of-therapy restrictions, combination therapy rules — your prior auth team needs the updated checklist before the next submission. An auth granted under old criteria may not protect you if the claim criteria changed. |
| 4 | Verify molecular testing documentation in your records. Aetna's medical necessity standard for amivantamab-vmjw is anchored to confirmed EGFR exon 20 insertion mutation status. Your documentation must show the specific test performed, the result, and the lab. If the CPB 0995 modification tightened this requirement — requiring specific approved tests or adding turnaround time standards — claims without that documentation will fail. |
| 5 | Check your ICD-10 coding for NSCLC and mutation status. The right primary diagnosis code (metastatic NSCLC) paired with the correct mutation-related secondary code is non-negotiable for medical necessity alignment. A mismatch between your ICD-10 coding and the mutation documentation in the chart is a denial trigger. Verify your coders are using current ICD-10-CM codes for EGFR mutation-positive NSCLC. |
| 6 | Flag any claims for combination regimens — especially amivantamab plus lazertinib. If the CPB 0995 modification specifically addressed the lazertinib combination (the PAPILLON regimen), your billing team needs to know whether Aetna now covers it, restricts it, or requires additional prior auth criteria. Don't assume prior approval for monotherapy covers combination use. |
| 7 | Brief your oncology nurses and infusion staff on documentation requirements. The billing chain for expensive biologics like Rybrevant breaks when clinical documentation doesn't match billing documentation. Your infusion team should know what Aetna requires in the medical record — not just what the chart contains. |
If you're uncertain how this modification applies to your specific patient population or payer mix, talk to your compliance officer before April 23, 2026 claims age into denial territory.
| 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 Amivantamab-vmjw Under CPB 0995
The policy data available for this modification does not list specific CPT, HCPCS, or ICD-10 codes. Do not use fabricated codes from this post.
For amivantamab-vmjw billing, your team should confirm the following directly from Aetna's full CPB 0995 document and your drug reimbursement resources:
- The current HCPCS J-code for amivantamab-vmjw IV (Rybrevant)
- The current HCPCS J-code for amivantamab-vmjw-rybp subcutaneous (if billed separately)
- The applicable ICD-10-CM codes for metastatic NSCLC with EGFR exon 20 insertion mutation
- Any infusion administration CPT codes Aetna ties to the drug coverage criteria
Cross-reference your J-codes against the current CMS HCPCS fee schedule and your Aetna contract. J-code assignments for newer biologics update more frequently than most billing teams track — and a stale code is a clean denial.
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