CommercialPrior AuthMedium impact
Nedosiran (Rivfloza) (CPB 1047, reviewed 2026-02-20)
Aetna·Genetics, Nephrology, Urology +1 more·Medical Policy
Effective date
Feb 20, 2026
We identified it
Aug 16, 2026
Summary
Aetna has issued a new Clinical Policy Bulletin (CPB 1047) effective 2026-02-20 establishing coverage criteria for nedosiran (Rivfloza), an RNA interference therapy for primary hyperoxaluria type 1 (PH1). The policy requires precertification for all members, limits use to patients age 2+ with confirmed PH1 diagnosis, eGFR ≥30 mL/min/1.73m², and prohibits concurrent use with lumasiran. Billing teams must implement precertification requirements and update systems to enforce all coverage criteria before processing claims.
Action Required
By 2026-02-20: Billing and precertification teams must implement the following: (1) Update billing software to require mandatory precertification for all nedosiran (Rivfloza) claims before submission via phone (866) 752-7021 or fax (888) 267-3277; (2) Configure system edits to block claims for patients under age 2, with eGFR <30, with prior liver transplant (Z94.4), or receiving concurrent lumasiran (J0224); (3) Ensure prior authorization forms document confirmation of PH1 diagnosis via AGXT genetic testing OR liver enzyme analysis showing absent/reduced AGT activity; (4) Verify claims include evidence of elevated urinary oxalate, oxalate:creatinine ratio, or plasma oxalate levels prior to therapy initiation; (5) Train providers that nedosiran must be prescribed by or in consultation with geneticist, nephrologist, or urologist; (6) Route all requests through Aetna's GCIT (Gene-based, Cellular & Other Innovative Therapies) team for Commercial lines; (7) Configure system rules to allow continuation of therapy only for members demonstrating positive response (decreased/normalized oxalate levels, improved kidney function). Failure to obtain precertification will result in claim denials. All PH2 (E72.538) and PH3 indications remain experimental and non-covered.