C65.1 Insurance Policy Changes

ICD-10 C65.1 is officially defined as "Malignant neoplasm of right renal pelvis." code C65.1 is referenced in 11 tracked payer policy changes from Blue Cross Blue Shield of North Dakota, 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 C65.1 is critical to clean claim submission. Each entry below links to the full policy analysis with effective dates and action steps.

Blue Cross Blue Shield of North Dakota · Effective Jan 13, 2026Medium impact
Pharmacy Policies Updates
BCBSND's Commercial post service claim edit medical drug policies have revisions effective Dec. 1, 2025, and its Commercial prior authorization medical drug policies have revisions effective Jan. 13, 2026. Most of these policies now separate Length of Authorization durations for initial and renewal periods, add the Appendix A Non-Quantitative Treatment Limitations (NQTL) Factor Checklist, and replace 'coverage' with 'prior authorization validity' in the initial and renewal criteria. Several policies also remove discontinued HCPCS codes, add ICD-10 covered diagnosis codes, and update oncology criteria to align with NCCN guidelines.
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 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 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 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.
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.

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FREQUENTLY ASKED QUESTIONS

What insurance policy changes affect code C65.1?

There are 11 tracked policy changes affecting code C65.1, including updates from Blue Cross Blue Shield of North Dakota, Excellus BlueCross BlueShield, Aetna. Each change may modify coverage criteria, reimbursement rates, or prior-authorization requirements.

Which payers have updated policy for code C65.1?

Payers that have issued tracked updates for code C65.1 include: Blue Cross Blue Shield of North Dakota, Excellus BlueCross BlueShield, Aetna, Blue Cross & Blue Shield of Mississippi.

How do I get notified when code C65.1 policy changes?

Create a free account at PolicyChanges.app and save a search filtered to code C65.1. 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 C65.1?

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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Pharmacy Policies Updates

Stereotactic Radiosurgery and Stereotactic Body Radiation Therapy 6.01.12

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)

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

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)

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

What insurance policy changes affect code C65.1?

Which payers have updated policy for code C65.1?

How do I get notified when code C65.1 policy changes?

Why do payers change policies for code C65.1?