CommercialPrior AuthHigh impact
Mitomycin Intravesical Solution (Zusduri) (CPB 1086, reviewed 2026-03-13)
Aetna·Urology, Oncology·Medical Policy
Effective date
Oct 3, 2025
We identified it
Aug 16, 2026
Summary
Aetna has established coverage for Zusduri (mitomycin intravesical solution) for treatment of recurrent low-grade intermediate-risk non-muscle invasive bladder cancer, effective October 3, 2025. All claims require precertification before administration. Billing teams must implement prior authorization workflows and ensure proper coding for the 6-week treatment protocol.
Action Required
By September 1, 2025: Implement mandatory precertification workflow for all Zusduri claims. Billing team must: (1) Update billing system to flag CPT 51720 and HCPCS J9282 claims for automatic precertification requirement; (2) Create precertification submission process with Aetna specialty pharmacy using phone (866) 752-7021 or fax (888) 267-3277; (3) Ensure providers document that treatment is 6 doses administered once weekly for six weeks at 75 mg dose via intravesical instillation; (4) Train front desk and billing staff that all Zusduri cases require Statement of Medical Necessity (SMN) precertification forms before service delivery; (5) Verify patient bladder integrity documentation and absence of perforated bladder in clinical record before authorizing claims. Consequence: Claims submitted without precertification will be denied. Update encounter forms and EMR templates to include precertification requirement flag for bladder cancer cases.