CommercialPrior AuthMedium impact
Sodium Thiosulfate (Pedmark) (CPB 1020, reviewed 2026-08-07)
Aetna·Oncology, Pediatrics·Medical Policy
Effective date
Jan 10, 2023
We identified it
Aug 16, 2026
Summary
Aetna has established a new medical policy (CPB 1020) for Sodium Thiosulfate (Pedmark) coverage in pediatric patients receiving cisplatin chemotherapy. The policy requires precertification for all uses and covers the drug only when administered to reduce ototoxicity risk in patients 1 month or older receiving cisplatin for localized, non-metastatic solid tumors with infusions not exceeding 6 hours. Billing teams must implement prior authorization requirements and ensure claims include appropriate ICD-10 diagnosis codes for malignant solid tumors.
Action Required
Immediate: Billing team must implement mandatory precertification for all Sodium Thiosulfate (Pedmark) claims submitted to Aetna commercial plans. Update billing system to flag CPT 96365 with HCPCS J0208 for prior authorization requirement before claim submission. Establish process for providers to call (866) 752-7021 or fax (888) 267-3277 for precertification approval and Statement of Medical Necessity (SMN) forms. Ensure all claims include verification that: (1) patient is 1 month of age or older, (2) cisplatin infusion duration does not exceed 6 hours, (3) solid tumor is localized and non-metastatic, and (4) appropriate ICD-10 diagnosis code from covered list (C00.0-C90.02, C90.20-C90.32, C96.0-D09.9, or T45.1X5A-T45.1X5S) is included. Claims submitted without precertification or meeting criteria will be denied. Providers and front desk staff must be trained on precertification requirements immediately.