Tislelizumab-jsgr (Tevimbra) — CPB 1057 | AETNA Coverage Update

Aetna modified CPB 1057 for tislelizumab-jsgr (Tevimbra), effective December 6, 2025. Here's what billing teams need to do.

Aetna, a CVS Health company, updated its Tevimbra coverage policy under CPB 1057 in the Aetna system to expand covered indications across multiple oncology specialties. The primary billing code is HCPCS J9329 (injection, tislelizumab-jsgr, 1 mg), billed alongside CPT 96413 and 96415 for IV infusion administration. If your practice treats GI cancers, hepatocellular carcinoma, head and neck malignancies, or hematologic cancers, this update directly affects your prior authorization workflow and your claim submission strategy.

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Quick-Reference Table

Field	Detail Copy
Payer	Aetna
Policy	Tislelizumab-jsgr (Tevimbra) — CPB 1057
Policy Code	CPB 1057
Change Type	Modified
Effective Date	December 6, 2025
Impact Level	High
Specialties Affected	Medical oncology, hematology/oncology, GI oncology, hepatology, head and neck oncology
Key Action	Confirm PD-L1 status and prior treatment history are documented before submitting precertification for J9329

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Aetna Tislelizumab-jsgr Coverage Criteria and Medical Necessity Requirements 2025

The Aetna Tevimbra coverage policy under CPB 1057 is indication-specific and biomarker-driven. Medical necessity approval depends on the cancer type, line of therapy, PD-L1 expression, and HER2 status. Get these details documented before you call for precertification.

Precertification is required for all Aetna participating providers and members in applicable plan designs. Call (866) 752-7021 or fax (888) 267-3277. You can also submit via the Specialty Pharmacy Precertification form on Aetna's provider portal.

The site-of-care utilization management policy also applies. Aetna's infusion site-of-care rules govern where J9329 can be administered for reimbursement. Confirm site eligibility before scheduling the first infusion or you risk a site-of-service claim denial.

Esophageal and Esophagogastric Junction Cancer

Tislelizumab-jsgr billing for esophageal cancer covers three distinct scenarios. First, first-line therapy for members with PD-L1 ≥ 1 and squamous cell carcinoma or HER2-negative adenocarcinoma, in combination with platinum-containing chemotherapy. Second, subsequent therapy for esophageal squamous cell carcinoma as a single agent. Third, induction therapy to relieve dysphagia before planned esophagectomy, in combination with platinum-containing chemotherapy, for members with PD-L1 ≥ 1.

Members must be non-surgical candidates or have unresectable, recurrent, or metastatic disease to qualify under the first two scenarios. The induction/esophagectomy path has its own criteria — don't conflate it with the metastatic indication when you document medical necessity.

Gastric Cancer

Aetna covers Tevimbra for HER2-negative gastric adenocarcinoma that is unresectable, recurrent, or metastatic. Coverage requires first-line use in combination with platinum and fluoropyrimidine-based chemotherapy. PD-L1 expression must be ≥ 1. Use ICD-10 codes C16.0 through C16.9 depending on tumor location within the stomach.

Anal Carcinoma

Coverage applies as a single agent for subsequent treatment of metastatic anal carcinoma. ICD-10 codes C21.0 through C21.8 apply here. This is a single-line indication — it does not cover first-line use.

Head and Neck Cancer (Nasopharyngeal)

Aetna covers Tevimbra in combination with cisplatin and gemcitabine for subsequent treatment of metastatic nasopharyngeal cancer. ICD-10 codes C11.0 through C11.9 apply. Confirm the treatment is subsequent-line — first-line nasopharyngeal use is not covered under this policy.

Hepatocellular Carcinoma

This indication has two approval paths. For first-line treatment, the member must have unresectable disease and be ineligible for transplant, or have extrahepatic/metastatic disease and be ineligible for resection, transplant, or locoregional therapy. For subsequent treatment, coverage applies to unresectable or extrahepatic/metastatic disease as a single agent. Use ICD-10 C22.0 for both paths. Document ineligibility for transplant or locoregional therapy explicitly in your precertification submission.

Histologic (Richter) Transformation to Diffuse Large B-Cell Lymphoma

Aetna covers Tevimbra in combination with zanubrutinib for Richter transformation to diffuse large B-cell lymphoma. ICD-10 codes C83.30 through C83.3A apply. This is a narrow hematologic indication — confirm the pathology report documents the Richter transformation before billing.

Small Bowel Adenocarcinoma and Other GI Indications

The policy also covers small bowel adenocarcinoma (ICD-10 C17.0–C17.9) and advanced or metastatic appendiceal carcinoma (ICD-10 C18.0–C18.9). Rectal cancer (C20) also appears in the code set. Review the full policy at the source for the specific criteria governing each of these indications, as the policy summary was truncated in available data.

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Aetna Tevimbra Exclusions and Non-Covered Indications

This is a hard stop that will generate a claim denial every time. Aetna explicitly excludes members who have experienced disease progression while on any PD-1 or PD-L1 inhibitor therapy.

The related HCPCS codes in the policy — J9022 (atezolizumab), J9023 (avelumab), J9119 (cemiplimab-rwlc), J9173 (durvalumab), J9271 (pembrolizumab), and J9299 (nivolumab) — are listed as context codes, not covered codes under this policy. They signal what prior therapy looks like. If a member has progressed on pembrolizumab (J9271) or nivolumab (J9299), Tevimbra is not covered. Document prior therapy history carefully.

This exclusion matters because oncology patients often cycle through checkpoint inhibitors. Confirm prior treatment lines before submitting precertification for J9329.

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Coverage Indications at a Glance

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Aetna Tevimbra Billing Guidelines and Action Items 2025

The effective date is December 6, 2025. If you're billing J9329 now or planning to, these steps apply immediately.

Copy Action Items

If you're unsure how the PD-1/PD-L1 progression exclusion applies to a specific patient's treatment history, loop in your compliance officer before submitting the precertification request.

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CPT, HCPCS, and ICD-10 Codes for Tislelizumab-jsgr Under CPB 1057

Covered HCPCS Codes (When Selection Criteria Are Met)

Code	Type	Description Copy
J9329	HCPCS	Injection, tislelizumab-jsgr, 1 mg

CPT Administration Codes

Code	Type	Description Copy
96413	CPT	Chemotherapy administration, IV infusion technique; up to 1 hour, single or initial substance/drug
96415	CPT	Chemotherapy administration, IV infusion technique; each additional hour (list in addition to code for primary procedure)

Reference HCPCS Codes (Prior Checkpoint Inhibitor Therapy — Not Covered Under CPB 1057)

Key ICD-10-CM Diagnosis Codes

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