Medicare AdvantagePrior AuthMedium impact
Adstiladrin (nadofaragene firadenovec-vncg) (Revised)
Humana·FL, SC · Oncology, Urology·Medicaid
Effective date
Sep 4, 2023
We identified it
Jun 25, 2026
Summary
Humana has updated its prior authorization policy for Adstiladrin (nadofaragene firadenovec-vncg), a gene therapy for high-risk BCG-unresponsive non-muscle invasive bladder cancer. The policy, revised June 24, 2026, applies to Medicare and Medicaid members in Florida and South Carolina. Billing teams must implement prior authorization requirements with specific clinical criteria before claims can be approved.
Action Required
Before submitting any Adstiladrin claims for Medicare or Medicaid (FL/SC) members: (1) Billing team must update claim submission workflows to require prior authorization for all Adstiladrin intravesical suspension administrations. (2) Verify patient meets ALL four approval criteria before submission: age ≥18, BCG-unresponsive disease (≥5 of 6 initial induction doses plus maintenance/second induction), NMIBC with documented carcinoma in situ, and ineligible for or refused cystectomy. (3) Clinical staff must document adequate BCG therapy definition in patient record. (4) Billing team must flag and deny any claims where patient has disease progression on Adstiladrin (Exclusion #1). (5) Set approval duration tracking to 6-month intervals for initial and renewal authorizations. (6) Train providers to submit supporting documentation with prior authorization requests per www.humana.com/PAL. Failure to obtain prior authorization will result in claim denials.