Aetna modified CPB 1005 for tebentafusp-tebn (Kimmtrak), effective September 26, 2025. Here's what billing teams need to act on now.
Aetna, a CVS Health company, updated its Kimmtrak coverage policy under CPB 1005 Aetna system. The policy governs tebentafusp-tebn billing for commercial plan members with unresectable or metastatic uveal melanoma. HCPCS code J9274 is the primary drug code covered when selection criteria are met, paired with infusion administration codes CPT 96413 through 96417 and IV infusion codes 96365 through 96368.
Quick-Reference Table
| Field | Detail |
|---|---|
| Payer | Aetna, a CVS Health company |
| Policy | Tebentafusp-tebn (Kimmtrak) — CPB 1005 |
| Policy Code | CPB 1005 |
| Change Type | Modified |
| Effective Date | September 26, 2025 |
| Impact Level | High |
| Specialties Affected | Oncology, Ocular Oncology, Infusion, Hematology-Oncology |
| Key Action | Confirm precertification is in place before submitting J9274 claims — no precert means denial |
Aetna Tebentafusp-tebn Coverage Criteria and Medical Necessity Requirements 2025
The Aetna Kimmtrak coverage policy under CPB 1005 requires precertification for all participating providers and members in applicable plan designs. No exceptions. If your practice hasn't built precert into the front-end workflow for this drug, that's the first problem to fix before September 26, 2025.
Tebentafusp-tebn targets uveal melanoma — specifically malignant neoplasms of the choroid and ciliary body. The ICD-10 codes in scope are C69.30, C69.31, C69.32 (choroid, unspecified and bilateral), and C69.40, C69.41, C69.42 (ciliary body). The policy language specifies these as unresectable or metastatic presentations.
Medical necessity under this Aetna coverage policy means the diagnosis must match one of those six ICD-10 codes exactly. Uveal melanoma is a narrow diagnosis — it's not the same as cutaneous melanoma, and the codes are not interchangeable. Make sure your ICD-10 selection reflects the ocular primary site, not a generalized melanoma code.
For prior authorization, call Aetna at (866) 752-7021 or fax (888) 267-3277. Statement of Medical Necessity forms are available through Aetna's Specialty Pharmacy Precertification page. Build these contact numbers into your infusion center's precert intake process now.
Reimbursement for tebentafusp-tebn runs through HCPCS J9274, billed per microgram. Pair that with the appropriate chemotherapy administration code — CPT 96413 for the initial hour, 96415 for each additional hour — or IV infusion codes if the clinical context dictates. Picking the wrong administration code is a fast path to a claim denial, so confirm your charge capture maps correctly to the infusion type documented in the clinical record.
This policy applies to commercial medical plans only. For Medicare criteria, Aetna directs providers to its Medicare Part B step therapy page. Don't apply CPB 1005 commercial criteria to Medicare patients — the rules are different.
Coverage Indications at a Glance
| Indication | Status | Relevant Codes | Notes |
|---|---|---|---|
| Unresectable or metastatic malignant neoplasm of choroid, unspecified eye | Covered (when criteria met) | J9274, C69.30 | Precertification required |
| Unresectable or metastatic malignant neoplasm of right choroid | Covered (when criteria met) | J9274, C69.31 | Precertification required |
| Unresectable or metastatic malignant neoplasm of left choroid | Covered (when criteria met) | J9274, C69.32 | Precertification required |
| Unresectable or metastatic malignant neoplasm of ciliary body, unspecified eye | Covered (when criteria met) | J9274, C69.40 | Precertification required |
| Unresectable or metastatic malignant neoplasm of right ciliary body | Covered (when criteria met) | J9274, C69.41 | Precertification required |
| Unresectable or metastatic malignant neoplasm of left ciliary body | Covered (when criteria met) | J9274, C69.42 | Precertification required |
| Medicare plan members | See separate criteria | — | CPB 1005 does not govern Medicare — refer to Aetna Medicare Part B page |
Aetna Kimmtrak Billing Guidelines and Action Items 2025
The real risk here isn't understanding the policy — it's execution. Tebentafusp-tebn is an expensive drug in a narrow indication. One missing precert or one wrong ICD-10 code produces a full claim denial. Here's what to do before September 26, 2025.
| # | Action Item |
|---|---|
| 1 | Audit your precertification workflow for J9274 today. If tebentafusp-tebn billing isn't already flagged as requiring prior authorization in your practice management system, fix that before the effective date. Every J9274 claim without an active precert authorization number is a denial waiting to happen. |
| 2 | Confirm ICD-10 mapping at the charge capture level. Your charge capture for Kimmtrak should default to one of the six covered codes: C69.30–C69.32 or C69.40–C69.42. If your oncologists are documenting "uveal melanoma" without specifying laterality or primary site, that's a documentation gap. Push it back to the clinical team now. |
| 3 | Verify the administration code matches the clinical record. Bill CPT 96413 for the initial chemotherapy infusion hour. Add CPT 96415 for each additional hour. If the drug is administered as a sequential infusion, CPT 96417 applies for each additional sequential drug. Don't default to CPT 96365 (standard IV infusion) when the record supports a chemotherapy administration code — the reimbursement difference matters, and so does accuracy. |
| 4 | Separate commercial and Medicare workflows. CPB 1005 governs commercial plans only. If your practice treats patients on both commercial Aetna and Medicare Advantage plans, make sure your precert team knows to follow Medicare Part B criteria — not this CPB — for Medicare patients. Mixing those workflows is a common source of claim denial and compliance exposure. |
| 5 | Document medical necessity in the chart before submitting the precert request. Aetna will review the clinical record against its Kimmtrak coverage policy criteria. The chart needs to support unresectable or metastatic status for the choroid or ciliary body primary site. Vague documentation delays authorization and slows payment. |
| 6 | Store the precert authorization number and attach it to every claim. For a drug at this price point, don't let authorization fall off between precert approval and claim submission. Build a verification step into your billing guidelines so the auth number is confirmed before the claim goes out the door. |
If you're uncertain how this policy applies to your specific commercial plan mix — especially if you have carve-out plans or ASO accounts — talk to your compliance officer before September 26, 2025.
| 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 Tebentafusp-tebn (Kimmtrak) Under CPB 1005
Covered HCPCS Code (When Selection Criteria Are Met)
| Code | Type | Description |
|---|---|---|
| J9274 | HCPCS | Injection, tebentafusp-tebn, 1 microgram |
Chemotherapy Administration CPT Codes
These codes apply to the infusion administration of tebentafusp-tebn. Select the correct code based on what the clinical record supports — initial vs. additional hours, and sequential vs. concurrent administration.
| Code | Type | Description |
|---|---|---|
| 96413 | CPT | Chemotherapy administration, intravenous infusion technique; up to 1 hour, single or initial substance/drug |
| 96414 | CPT | Chemotherapy administration, intravenous infusion technique; each additional hour |
| 96415 | CPT | Chemotherapy administration, intravenous infusion technique; each additional hour (sequential infusion) |
| 96416 | CPT | Chemotherapy administration, intravenous infusion technique; initiation of prolonged chemotherapy infusion |
| 96417 | CPT | Chemotherapy administration, intravenous infusion technique; each additional sequential infusion (different substance/drug) |
IV Infusion CPT Codes (Related to CPB)
| Code | Type | Description |
|---|---|---|
| 96365 | CPT | Intravenous infusion, for therapy, prophylaxis, or diagnosis; initial, up to 1 hour |
| 96366 | CPT | Intravenous infusion, for therapy, prophylaxis, or diagnosis; each additional hour |
| 96367 | CPT | Intravenous infusion, for therapy, prophylaxis, or diagnosis; additional sequential infusion of a new drug/substance |
| 96368 | CPT | Intravenous infusion, for therapy, prophylaxis, or diagnosis; concurrent infusion |
Key ICD-10-CM Diagnosis Codes
All six codes below reflect uveal melanoma at the choroid or ciliary body, designated unresectable or metastatic under CPB 1005.
| Code | Description |
|---|---|
| C69.30 | Malignant neoplasm of choroid, unspecified eye [unresectable or metastatic] |
| C69.31 | Malignant neoplasm of right choroid [unresectable or metastatic] |
| C69.32 | Malignant neoplasm of left choroid [unresectable or metastatic] |
| C69.40 | Malignant neoplasm of ciliary body, unspecified eye [unresectable or metastatic] |
| C69.41 | Malignant neoplasm of right ciliary body [unresectable or metastatic] |
| C69.42 | Malignant neoplasm of left ciliary body [unresectable or metastatic] |
One point worth flagging on the administration codes: Aetna lists CPT 96413–96417 as chemotherapy administration codes and 96365–96368 as "other CPT codes related to the CPB." The policy doesn't draw a hard line between them in terms of coverage status — but your medical necessity documentation and clinical context should drive which family of codes you use. Chemotherapy administration codes (96413 series) are the right choice when the clinical record reflects antineoplastic drug infusion. If your infusion team is routinely defaulting to 96365 for Kimmtrak, that's worth reviewing with your billing consultant.
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