Mogamulizumab-kpkc (Poteligeo) (CPB 0940, reviewed 2026-04-28)

IMMEDIATELY: Billing team must implement coverage validation for Poteligeo (mogamulizumab-kpkc) claims under Aetna commercial medical plans. (1) Update billing system to recognize HCPCS code J9204 as covered ONLY when submitted with ICD-10 diagnosis codes C84.00-C84.09 (mycosis fungoides), C84.10-C84.19 (Sézary syndrome), or C91.50-C91.52 (ATLL) AND clinical documentation supporting one of the three approved indications: (a) ATLL as single-agent subsequent therapy for chronic high-risk, acute, or lymphoma subtypes; (b) ATLL in combination with CHOP without transplant intent; or (c) Mycosis fungoides or Sézary syndrome. (2) Flag all claims with J9204 for medical necessity review before submission; claims lacking qualifying diagnosis codes or approved indication will be denied. (3) Configure system to allow continuation claims only when prior authorization documents no disease progression or unacceptable toxicity. (4) Educate providers and clinical staff that all other indications (beyond the three approved uses) are experimental/investigational and non-covered. (5) Reject claims submitted without indication that dosing follows Poteligeo protocol: 1 mg/kg IV infusion over minimum 60 minutes on days 1, 8, 15, 22 of first 28-day cycle, then days 1 and 15 of subsequent cycles. Failure to implement will result in claim denials and patient billing disputes.