ICD-10 C68.0 is officially defined as "Malignant neoplasm of urethra." code C68.0 is referenced in 9 tracked payer policy changes from Aetna. For billers and coders, staying current on payer-specific coverage criteria, reimbursement rules, and prior-authorization requirements for code C68.0 is critical to clean claim submission. Each entry below links to the full policy analysis with effective dates and action steps.
Aetna's commercial policy for Trodelvy (sacituzumab govitecan-hziy) was reviewed on 10/29/2026. Its breast cancer criteria include two first-line triple-negative uses that the FDA approved on June 24, 2026: Trodelvy as a single agent, and Trodelvy with pembrolizumab for PD-L1 positive disease (CPS 10 or higher). The source gives no separate effective date for Aetna's change, and precertification is still required.
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 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 considers brachytherapy medically necessary for breast, esophageal, eye tumors, genitourinary cancers other than bladder, gynecologic, head and neck, respiratory and digestive tract, and soft tissue sarcoma indications when the EviCore Healthcare Radiation Therapy Clinical Guidelines criteria are met. It also considers brachytherapy medically necessary for skin cancer where surgical resection and photon or electron beam techniques are contraindicated, and for stenotic obstruction after lung transplantation refractory to other treatments. Brachytherapy for bladder cancer, bone metastases, brain tumors, leukemia, lymphoma, multiple myeloma, pancreatic cancer, keloids, palmoplantar pustulosis, spinal tumors and spinal metastases, and subfoveal choroidal neovascularization secondary to age-related macular degeneration is considered experimental, investigational or unproven, and electronic brachytherapy is considered experimental, investigational or unproven for breast cancer and all other indications.
Aetna's Clinical Policy Bulletin 0811 considers autologous or allogeneic hematopoietic stem cell transplant, both ablative and non-myeloablative, experimental, investigational, or unproven for the following adult solid tumors: bile duct (cholangiocarcinoma), breast, central nervous system tumors, cervix, colon, esophagus, fallopian tube, gallbladder, kidney, liver, lung, melanoma, nasopharynx, neuroendocrine tumors, pancreas, paranasal sinus, prostate, rectum, soft tissue sarcomas, stomach, thymus, thyroid, tumors of unknown primary origin, and uterus. Aetna considers autologous hematopoietic stem cell transplant medically necessary in young adults with primitive neuroectodermal tumors, medulloblastoma, and Ewing sarcoma family of tumors when criteria are met in CPB 0496.
Aetna requires precertification for Trodelvy (sacituzumab govitecan-hziy) for participating providers and members in applicable plan designs. Aetna considers Trodelvy medically necessary for HER2-negative recurrent unresectable or metastatic breast cancer, or disease with no response to preoperative systemic therapy, when specific prior-treatment criteria are met, and for urothelial carcinoma as a single agent after platinum-containing chemotherapy and a PD-1 or PD-L1 inhibitor. Continuation is medically necessary when there is no evidence of unacceptable toxicity or disease progression on the current regimen, and all other indications are considered experimental, investigational, or unproven.
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 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's criteria cover avelumab (Bavencio) for Merkel cell carcinoma as a single agent; first-line advanced renal cell carcinoma with clear cell histology in combination with axitinib; urothelial carcinomas (bladder cancer, primary carcinoma of the urethra, upper genitourinary tract tumors, and urothelial carcinoma of the prostate) as subsequent therapy or as maintenance therapy when there is no progression on first-line platinum-containing chemotherapy; gestational trophoblastic neoplasia; recurrent endometrial carcinoma (as a single agent when MSI-H or dMMR, or with axitinib when pMMR); thymic carcinoma with axitinib; relapsed or refractory extranodal NK/T-cell lymphoma; and colorectal or small bowel adenocarcinoma that is dMMR/MSI-H or POLE/POLD1 ultra-hypermutated, as a single agent or as neoadjuvant treatment of up to 6 months. Members who have experienced disease progression while on PD-1 or PD-L1 inhibitor therapy are not eligible, and all other indications are considered experimental, investigational or unproven. This policy addresses avelumab for commercial medical plans, where precertification is required and the Site of Care Utilization Management Policy applies.
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