C64.9 Insurance Policy Changes

ICD-10 C64.9 is officially defined as "Malignant neoplasm of unspecified kidney, except renal pelvis." code C64.9 is referenced in 22 tracked payer policy changes from Wisconsin Medicaid (ForwardHealth), Excellus BlueCross BlueShield, and 2 other payers. For billers and coders, staying current on payer-specific coverage criteria, reimbursement rules, and prior-authorization requirements for code C64.9 is critical to clean claim submission. Each entry below links to the full policy analysis with effective dates and action steps.

Wisconsin Medicaid (ForwardHealth) · Effective Oct 1, 2026Medium impact
ForwardHealth Covers Dental Case Management for Members With Special Health Care Needs
Beginning October 1, 2026, ForwardHealth covers dental case management for members with special health care needs, reimbursed under CDT code D9997 at $100 per visit. Prior authorization is required for more than one visit per member within 180 days, for D9997 billed with moderate to deep dental sedation in that period, for a member whose diagnosis is not a qualifying code but has documented medical necessity, and when the place of service is 15 (Mobile Unit). Prior authorization is not required for the first visit per member, per provider, every six months (180 days).
Excellus BlueCross BlueShield · Effective Nov 16, 2025Medium impact
Stereotactic Radiosurgery and Stereotactic Body Radiation Therapy 6.01.12
Excellus BlueCross BlueShield stereotactic radiosurgery and stereotactic body radiation therapy medical policy 6.01.12 has a current effective date of November 16, 2025. Its October 16, 2025 annual review removed life expectancy criteria from the policy criteria. SRS is considered medically appropriate for specified benign, brain and neurologic indications, SBRT is considered medically appropriate for specified extracranial cancers and oligometastatic disease, and SBRT is considered not medically necessary for indications including extrahepatic bile duct cancer, gallbladder cancer and chronic pain.
Aetna · Identified Nov 4, 2026Medium impact
Nivolumab Products (Opdivo, Opdivo Qvantig, and Opdualag) (CPB 0892, reviewed 2026-10-28)
Aetna's clinical policy bulletin CPB 0892, last reviewed 2026-10-28, sets the coverage criteria for nivolumab (Opdivo), nivolumab and hyaluronidase-nvhy (Opdivo Qvantig), and nivolumab and relatlimab-rmbw (Opdualag) for Aetna commercial medical plans, including indication-by-indication initial approval criteria, continuation-of-therapy criteria, and dosing references. Precertification is required for all three products, and the site-of-care utilization management policy applies. The practice's billing team should align charge entry, precertification tracking, and documentation with the indications and continuation limits listed for each product.
Aetna · Identified Oct 19, 2026Medium impact
Mitomycin Pyelocalyceal Solution (Jelmyto) (CPB 0972, reviewed 2026-10-14)
Aetna's policy on Jelmyto (mitomycin pyelocalyceal solution) applies to commercial medical plans, and precertification is required. Aetna considers Jelmyto medically necessary for 6 doses of treatment of non-metastatic, low-grade, low-volume (5-15 mm) upper tract urothelial cancer when it is given by pyelocalyceal administration once weekly for the first six weeks. Continuation is covered for a maximum of 11 additional monthly doses after a complete response at 3 months, and all other indications are considered experimental, investigational, or unproven.
Aetna · Identified Oct 16, 2026Medium impact
Enfortumab Vedotin-ejfv (Padcev) (CPB 0967, reviewed 2026-10-09)
Aetna covers enfortumab vedotin-ejfv (Padcev) for commercial medical plans, and precertification of Padcev is required for Aetna participating providers and members in applicable plan designs. Aetna considers Padcev medically necessary for urothelial carcinoma when criteria are met, including as a single agent used as subsequent therapy after platinum-containing chemotherapy and prior PD-1 or PD-L1 inhibitor treatment, or as subsequent therapy for members ineligible for cisplatin-containing chemotherapy, and in combination with pembrolizumab or pembrolizumab and berahyaluronidase alfa-pmph for stage II, recurrent, locally advanced, or metastatic urothelial carcinoma. Aetna considers all other indications experimental, investigational, or unproven.
Aetna · Identified Oct 15, 2026Medium impact
Avelumab (Bavencio) (CPB 0916, reviewed 2026-10-14)
Aetna considers avelumab (Bavencio) medically necessary for commercial plan members with Merkel cell carcinoma, renal cell carcinoma in combination with axitinib, urothelial carcinomas, gestational trophoblastic neoplasia, endometrial carcinoma, thymic carcinoma, extranodal NK/T-cell lymphoma, colorectal adenocarcinoma, and small bowel adenocarcinoma when the criteria for each indication are met. Precertification of avelumab is required for all Aetna participating providers and members in applicable plan designs, and members who have experienced disease progression while on PD-1 or PD-L1 inhibitor therapy are not eligible. Aetna considers avelumab experimental, investigational, or unproven for all other indications, including breast cancer, non-small cell lung cancer, ovarian cancer, prostate cancer, and pancreatic cancer.
Aetna · Identified Oct 10, 2026Medium impact
Radiofrequency Tumor Ablation (CPB 0492, reviewed 2026-10-05)
Aetna considers radiofrequency ablation (RFA) medically necessary for indications that include colorectal cancer liver metastases, colorectal cancer lung metastases of 5 cm or less where the primary colorectal tumor has been resected for cure (R0 resection), malignant lung masses in persons who are not candidates for surgical intervention, solitary hepatocellular carcinoma of 5 cm or less or multinodular early-stage HCC in members who are ineligible for or decline surgical resection or transplantation, renal cell carcinoma up to 4 cm in high-risk surgical candidates or in persons with renal insufficiency or a solitary kidney, and osteoid osteoma in individuals who remain symptomatic despite NSAIDs. Aetna considers RFA experimental, investigational, or unproven for combined RFA with transarterial chemoembolization for intermediate-stage hepatocellular carcinoma, combined endoluminal RFA and stenting for malignant biliary obstruction or stricture, combined RFA and vertebral cement augmentation for spinal metastases, endoscopic ultrasound-guided RFA for aldosterone-producing adenomas, and all other indications, including curative treatment of primary or metastatic malignant neoplasms in persons able to tolerate surgical resection, biliary obstructions or strictures, renal cysts, renal angiomyolipomas, Brunner's gland hyperplasia, and unresectable localized recurrent thyroid cancers without distant metastases.
Aetna · Identified Oct 8, 2026Medium impact
Docetaxel (CPB 0956, reviewed 2026-10-05)
For commercial medical plans, docetaxel (Beizray, Docivyx, Taxotere, or generic docetaxel) is considered medically necessary for the listed cancer indications, including breast cancer, non-small cell lung cancer, prostate cancer, gastric cancer, head and neck cancer, ovarian cancer, small cell lung cancer, and soft tissue sarcoma. Breast cancer requires the disease-status criteria stated in the policy, and continuation of therapy is considered medically necessary when there is no evidence of unacceptable toxicity or disease progression on the current regimen. All other indications are considered experimental, investigational, or unproven.
Aetna · Identified Aug 17, 2026Medium impact
Hematopoietic Cell Transplantation for Selected Childhood Solid Tumors (CPB 0496, reviewed 2026-08-06)
Aetna considers autologous hematopoietic cell transplantation medically necessary as consolidation therapy for high-risk neuroblastoma when the member meets the transplanting institution's protocol selection criteria. Without a protocol, it is considered medically necessary when the stated criteria are met, including tandem autologous transplants for the common high-risk group and a single autologous transplant for the special high-risk groups. Autologous transplant is not medically necessary for members with progressive disease during or at the end of induction therapy. Autologous transplant is also addressed for chemosensitive relapsed or refractory neuroblastoma, relapsed or progressive chemosensitive Ewing's sarcoma family of tumors that is not widely metastatic, primitive neuroectodermal tumors including medulloblastoma and pineoblastoma, ependymoma in members ineligible for radiotherapy, extraocular retinoblastoma, and progressive or relapsed chemosensitive Wilms' tumor. Allogeneic hematopoietic cell transplantation for ependymoma, Ewing's sarcoma family of tumors, neuroblastoma, primitive neuroectodermal tumors, retinoblastoma and Wilms' tumor, adoptive cellular immunotherapy following transplantation for childhood solid tumors, and autologous transplantation for soft tissue sarcomas are considered experimental, investigational, or unproven.
Aetna · Identified Aug 17, 2026Medium impact
Flow Cytometry, Ektacytometry, DNA Ploidy, and S-phase Fraction (CPB 0351, reviewed 2026-05-21)
Aetna considers flow cytometry for cell surface markers medically necessary for listed conditions, including abnormal tissue, bone marrow or blood histology suspicious for lymphoma, leukemia or myelodysplastic syndrome, multiple myeloma, paroxysmal nocturnal hemoglobinuria, primary immunodeficiencies, Sezary syndrome diagnosis, and T-cell monitoring for HIV infection and AIDS. Flow-cytometry-derived DNA ploidy or S-phase fraction is medically necessary only in localized cancers without metastatic disease, namely endometrial adenocarcinoma, gastric cancer, mediastinal neuroblastoma, medulloblastoma, ovarian carcinoma, partial hydatidiform mole, prostatic adenocarcinoma, renal cell adenocarcinoma and urinary bladder carcinoma, and only when the prognostic information will affect treatment decisions. Ektacytometry is medically necessary for red blood cell cytoskeleton and hydration disorders when red blood cell morphology does not provide a clear diagnosis. The red blood cell adhesion index for all indications, DNA ploidy or S-phase testing in breast, cervical, colorectal, non-small cell lung, small cell lung and pediatric intracranial tumors, and microfluidic flow adhesion assays for sickle cell disease are experimental, investigational or unproven.
Aetna · Identified Aug 17, 2026Medium impact
Microwave Thermotherapy (CPB 0682, reviewed 2025-10-15)
Aetna considers microwave thermotherapy medically necessary for clinical stage T1 renal lesions, for medically inoperable non-small cell lung cancer lesions less than 3 cm, and for hepatocellular carcinoma tumors less than or equal to 3 cm. Aetna considers microwave thermotherapy experimental, investigational or unproven for bladder cancer, bone cancer and limb salvage, breast cancer and breast cancer metastasis, cervical ectopy, chronic low back and neck pain, chronic pelvic pain syndrome, chronic prostatitis, cutaneous verrucae, dysmenorrhea, endometrial cancer, keratoconus, nasopharyngeal cancer, osteosarcoma, pancreatic cancer, rheumatoid arthritis and vulvar lichen sclerosus. Microwave thermotherapy enhanced with hybrid magnetic nanoparticles for liver cancer and microwave thermotherapy combined with TIPE2 for colon cancer are also experimental, investigational or unproven.
Aetna · Identified Aug 16, 2026Medium impact
Fibroid Treatment (CPB 0304, reviewed 2026-04-17)
Aetna considers radiofrequency ablation or transcatheter uterine artery embolization medically necessary as an alternative to hysterectomy or myomectomy for uterine fibroids when the member has persistent symptoms directly attributed to the fibroids, such as excessive menstrual bleeding, bulk-related pelvic pain, pressure or discomfort, urinary symptoms from compression of the ureter or bladder, or dyspareunia. Aetna considers myomectomy or hysterectomy using power morcellation experimental, investigational, or unproven, except in women without known or strongly suspected uterine cancer who meet the listed exception criteria, such as premenopausal women who wish to maintain fertility and have no risk factors for uterine sarcoma. Aetna also considers cryomyolysis, cryotherapy, electrical ablation, interstitial thermotherapy, laparoscopic uterine artery occlusion, lasers, focused ultrasound ablation, acupuncture, and other uses of transcatheter uterine artery embolization experimental, investigational, or unproven.
Aetna · Identified Aug 16, 2026Medium impact
Mitomycin Pyelocalyceal Solution (Jelmyto) (CPB 0972, reviewed 2025-08-13)
Precertification from Aetna is required of participating providers and members in applicable commercial plan designs. Aetna considers mitomycin (Jelmyto) medically necessary for six doses of treatment of non-metastatic, low-grade, low volume (5-15 mm) upper tract urothelial cancer when the drug is given pyelocalyceally and administered once weekly for the first six weeks. Continuation therapy is considered medically necessary for a maximum of 11 additional monthly doses after a complete response at 3 months, and all other indications are considered experimental, investigational, or unproven. The recommended dose is 4 mg per mL via ureteral catheter or nephrostomy tube, not to exceed 15 mL (60 mg of mitomycin).
Aetna · Identified Aug 15, 2026Medium impact
Ipilimumab (Yervoy) (CPB 0815, reviewed 2026-07-16)
Aetna's Clinical Policy Bulletin 0815 covers ipilimumab (Yervoy) for commercial medical plans. It considers ipilimumab medically necessary for the cancer indications listed in the policy, many of them in combination with nivolumab, and considers continued treatment medically necessary for members requesting reauthorization when there is no evidence of unacceptable toxicity or disease progression. It considers ipilimumab experimental, investigational, or unproven for indications such as glioblastoma, pancreatic cancer, and prostate cancer, and for use with bevacizumab, vemurafenib, dabrafenib, or trametinib.
Aetna · Identified Aug 15, 2026Medium impact
Radium Ra 223 Dichloride (Xofigo) (CPB 0874, reviewed 2025-12-22)
Aetna considers a total of 6 injections of radium Ra 223 dichloride (Xofigo) medically necessary for treatment of bone metastases in members with castration-resistant prostate cancer when the criteria are met, and for subsequent treatment of osteosarcoma when the member has previously tried at least 2 systemic therapies. Aetna considers more than one course (a total of 6 injections) experimental, investigational, or unproven because the safety and efficacy of more than one course has not been established. The policy was last reviewed 12/22/2025. Its policy history lists an effective date of 10/17/2013 and a next review date of 10/22/2026.
Aetna · Identified Aug 14, 2026Medium impact
Embolization: Selected Procedures (CPB 0856, reviewed 2026-01-12)
Aetna considers alcohol embolization or sclerotherapy and/or surgery for symptomatic venous malformations medically necessary when there is pain, swelling, ulceration, or hemorrhage. Coil embolization is medically necessary for arterio-venous malformations and aneurysms, congenital aorto-azygous fistula, splenic artery aneurysm and gastric varices, and embolization is medically necessary for lower gastro-intestinal bleeding, for renal angiomyolipoma with active bleeding or a size greater than 6 cm, and for several other listed indications. Aetna considers hemorrhoidal embolization, endovascular lymphatic ablation, Onyx embolization for the treatment of CSF vertebral vein fistula, coil embolization of the hypogastric veins for deep vein thrombosis, and several other listed procedures experimental, investigational, or unproven.
Aetna · Identified Aug 13, 2026Medium impact
Enfortumab Vedotin-ejfv (Padcev) (CPB 0967, reviewed 2026-04-24)
Aetna Clinical Policy Bulletin 0967 covers enfortumab vedotin-ejfv (Padcev) for commercial medical plans and requires precertification for all Aetna participating providers and members in applicable plan designs. Aetna considers Padcev medically necessary for urothelial carcinoma as a single agent when it is used as subsequent therapy after platinum-containing chemotherapy and a PD-1 or PD-L1 inhibitor, or as subsequent therapy for members who are ineligible for cisplatin-containing chemotherapy, in the listed bladder, upper genitourinary tract, and prostate settings, and in combination with pembrolizumab or pembrolizumab and berahyaluronidase alfa-pmph for stage II, recurrent, locally advanced, or metastatic urothelial carcinoma. Aetna considers all other indications experimental, investigational, or unproven.
Aetna · Identified Aug 13, 2026Medium impact
Durvalumab (Imfinzi) (CPB 0917, reviewed 2026-06-25)
Aetna considers durvalumab (Imfinzi) medically necessary for commercial medical plans when the criteria for a listed indication are met, and considers all other indications experimental, investigational, or unproven. Precertification is required of all Aetna participating providers and members in applicable plan designs, and Aetna considers members not eligible for Imfinzi when they have experienced disease progression while on PD-1 or PD-L1 inhibitor therapy. Continuation of therapy is medically necessary when there is no evidence of unacceptable toxicity or disease progression on the current regimen, up to 12 months total for unresectable stage II or III NSCLC and up to 24 months total for limited stage SCLC.
Aetna · Identified Aug 13, 2026Medium impact
Paclitaxel, Albumin-Bound (CPB 0834, reviewed 2026-05-28)
Aetna considers albumin-bound paclitaxel (Abraxane or generic albumin-bound paclitaxel) medically necessary for the cancers listed in its initial approval criteria, including Kaposi sarcoma, breast cancer, cutaneous melanoma, endometrial carcinoma, ovarian, fallopian tube and primary peritoneal cancer, biliary tract cancers, non-small cell lung cancer, pancreatic adenocarcinoma, small bowel adenocarcinoma, uveal melanoma, ampullary adenocarcinoma, cervical cancer, bladder cancer and vaginal cancer, when each cancer's stated criteria are met. All other indications are considered experimental, investigational, or unproven, including small cell lung cancer, prostate cancer, soft-tissue sarcoma and gastric cancer. Continuation of therapy is medically necessary for an approved indication when there is no evidence of unacceptable toxicity or disease progression on the current regimen.
Aetna · Identified Aug 12, 2026Medium impact
Optical Coherence Tomography and Microelastography for Solid Tumors and Other Selected Indications (CPB 0886, reviewed 2026-03-03)
Aetna considers optical coherence tomography and microelastography experimental, investigational, or unproven for the listed intra-operative uses because their effectiveness has not been established. These uses include assessment of lymph nodes or tumor margins in breast conserving surgery, differentiation of pancreatic neoplastic lesions, differentiation of normal and diseased thyroid and parathyroid tissues, and solid tumor surgery including optical biopsy of lymph nodes and real-time determination of surgical margins. The policy lists CPT codes and ICD-10 codes as not covered for the indications it names.
Blue Cross & Blue Shield of Mississippi · Identified Jun 20, 2026Medium impact
Cryoablation of Tumors Located in the Kidney, Lung, Breast, Pancreas, or Bone
Cryosurgical ablation may be considered medically necessary to treat localized renal cell carcinoma no more than 4 cm in size when kidney function preservation is necessary or the individual is not a surgical candidate, and to treat lung cancer in an individual with early-stage non-small-cell lung cancer who is a poor surgical candidate or who requires palliation of a central airway obstructing lesion. It is considered investigational for benign or malignant tumors of the breast, lung other than as defined above, pancreas, or bone, and for renal cell carcinoma in individuals who are surgical candidates. The policy history records a 09/12/2025 review with no changes.
Aetna · Identified Nov 4, 2026Low impact
Microwave Thermotherapy (CPB 0682, reviewed 2026-10-26)
Aetna's Microwave Thermotherapy policy (CPB 0682) was reviewed on 2026-10-26, and the source does not state what changed or give a new effective date. It covers microwave thermotherapy as medically necessary only for T1 renal lesions, medically inoperable non-small cell lung cancer lesions under 3 cm, and hepatocellular carcinoma tumors of 3 cm or less, and it lists many other uses (such as breast, pancreatic, bladder, and chronic pain indications) as experimental, investigational or unproven.

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FREQUENTLY ASKED QUESTIONS

What insurance policy changes affect code C64.9?

There are 22 tracked policy changes affecting code C64.9, including updates from Wisconsin Medicaid (ForwardHealth), Excellus BlueCross BlueShield, Aetna. Each change may modify coverage criteria, reimbursement rates, or prior-authorization requirements.

Which payers have updated policy for code C64.9?

Payers that have issued tracked updates for code C64.9 include: Wisconsin Medicaid (ForwardHealth), Excellus BlueCross BlueShield, Aetna, Blue Cross & Blue Shield of Mississippi.

How do I get notified when code C64.9 policy changes?

Create a free account at PolicyChanges.app and save a search filtered to code C64.9. You will get an email when new policy changes reference this code: daily or weekly, your choice, on every plan.

Why do payers change policies for code C64.9?

Payers revise policies for individual billing codes to align with updated clinical guidelines, CMS rule changes, fraud and abuse prevention measures, or network cost-management goals. Changes can affect medical necessity criteria, place-of-service restrictions, bundling rules, or whether a code requires prior authorization.

All billing codes J3590 C9399 J3490 99215 99213 99202

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ForwardHealth Covers Dental Case Management for Members With Special Health Care Needs

Stereotactic Radiosurgery and Stereotactic Body Radiation Therapy 6.01.12

Nivolumab Products (Opdivo, Opdivo Qvantig, and Opdualag) (CPB 0892, reviewed 2026-10-28)

Mitomycin Pyelocalyceal Solution (Jelmyto) (CPB 0972, reviewed 2026-10-14)

Enfortumab Vedotin-ejfv (Padcev) (CPB 0967, reviewed 2026-10-09)

Avelumab (Bavencio) (CPB 0916, reviewed 2026-10-14)

Radiofrequency Tumor Ablation (CPB 0492, reviewed 2026-10-05)

Docetaxel (CPB 0956, reviewed 2026-10-05)

Hematopoietic Cell Transplantation for Selected Childhood Solid Tumors (CPB 0496, reviewed 2026-08-06)

Flow Cytometry, Ektacytometry, DNA Ploidy, and S-phase Fraction (CPB 0351, reviewed 2026-05-21)

Microwave Thermotherapy (CPB 0682, reviewed 2025-10-15)

Fibroid Treatment (CPB 0304, reviewed 2026-04-17)

Mitomycin Pyelocalyceal Solution (Jelmyto) (CPB 0972, reviewed 2025-08-13)

Ipilimumab (Yervoy) (CPB 0815, reviewed 2026-07-16)

Radium Ra 223 Dichloride (Xofigo) (CPB 0874, reviewed 2025-12-22)

Embolization: Selected Procedures (CPB 0856, reviewed 2026-01-12)

Enfortumab Vedotin-ejfv (Padcev) (CPB 0967, reviewed 2026-04-24)

Durvalumab (Imfinzi) (CPB 0917, reviewed 2026-06-25)

Paclitaxel, Albumin-Bound (CPB 0834, reviewed 2026-05-28)

Optical Coherence Tomography and Microelastography for Solid Tumors and Other Selected Indications (CPB 0886, reviewed 2026-03-03)

Cryoablation of Tumors Located in the Kidney, Lung, Breast, Pancreas, or Bone

Microwave Thermotherapy (CPB 0682, reviewed 2026-10-26)

What insurance policy changes affect code C64.9?

Which payers have updated policy for code C64.9?

How do I get notified when code C64.9 policy changes?

Why do payers change policies for code C64.9?