Pegaspargase (Oncaspar) (CPB 0959, reviewed 2025-12-03)

By 2025-12-03: Billing and clinical teams must implement the following: (1) Update billing system to require Aetna prior authorization for J9266 (pegaspargase) claims only when diagnosis codes match covered indications (C91.00-C91.02 for ALL; C83.51-C83.59 for LL; C86.00-C86.01 for ENKL; C94.80-C94.82 for ANKL) AND when multi-agent chemotherapy is documented. (2) Configure system to automatically deny or flag claims for pegaspargase when combined with anti-PD-1 antibody, anlotinib, and radiotherapy regimens, as this combination is marked experimental/investigational. (3) Add contraindication screening in EMR/billing system to prevent claims for patients with diagnosis codes K72.00, K72.01, K72.10, K72.11, K72.90, or K72.91 (hepatic failure conditions). (4) Train oncology and hematology providers that pegaspargase dosing must be documented as either 2,500 IU/m² (for patients ≤21 years) or 2,000 IU/m² (for patients >21 years) and administered no more frequently than every 14 days. (5) Update prior authorization request forms to require documentation of multi-agent chemotherapy regimen and patient age/BSA for dose verification. Claims submitted without proper authorization or for non-covered indications will be denied.