CommercialPrior AuthMedium impact
Denileukin Diftitox-cxdl (Lymphir) (CPB 1070, reviewed 2026-04-09)
Aetna·Oncology, Hematology·Medical Policy
Effective date
Nov 13, 2024
We identified it
Aug 13, 2026
Summary
Aetna has established a new medical policy (CPB 1070, effective 11/13/2024) covering denileukin diftitox-cxdl (Lymphir) for cutaneous T-cell lymphoma (CTCL) stages I-III on commercial plans. All claims require precertification before treatment. Billing teams must implement prior authorization workflows and ensure proper coding using HCPCS code J9161 with associated administration codes.
Action Required
Before 11/13/2024 or immediately upon receipt: (1) Billing team must update billing software to require precertification for HCPCS code J9161 (Lymphir injection) on all Aetna commercial plans. (2) Providers must obtain precertification by calling (866) 752-7021 or faxing (888) 267-3277 before administering Lymphir for stage I-III CTCL (ICD-10: C84.A0-C84.A9, C84.AA, C86.30-C86.31). (3) Add precertification requirement to the EMR/encounter form for oncology providers. (4) Ensure infusion administration codes (96365-96368 or 96413-96417) are billed with J9161. (5) For therapy continuation/reauthorization, verify no unacceptable toxicity or disease progression. All claims billed without precertification approval will be denied. Precertification forms available at Specialty Pharmacy Precertification portal.