CommercialPrior AuthMedium impact
Nadofaragene Firadenovec-vncg (Adstiladrin) (CPB 1024, reviewed 2025-12-10)
Aetna·Oncology, Urology·Medical Policy
Effective date
Mar 28, 2023
We identified it
Aug 16, 2026
Summary
Aetna has established coverage criteria for Adstiladrin (nadofaragene firadenovec-vncg), a gene therapy for bladder cancer. The policy covers treatment of high-risk, BCG-unresponsive non-muscle invasive bladder cancer with carcinoma in situ. All claims require precertification before treatment begins, and continuation requires reauthorization with evidence of response and acceptable toxicity.
Action Required
By immediately (retroactive to 03/28/2023): Billing team must implement precertification requirement for all Adstiladrin claims. Update billing system to flag CPT 50720 and HCPCS J9029 for prior authorization before submission. Providers must call (866) 752-7021 or fax (888) 267-3277 for precertification. Obtain Statement of Medical Necessity (SMN) forms from Specialty Pharmacy Precertification. Ensure all claims include ICD-10 code D09.0 and document high-risk status and BCG-unresponsiveness. For reauthorization, require evidence of complete response or disease stability with acceptable toxicity tolerance. Claims submitted without prior auth will be denied. Update encounter forms and billing workflows to enforce this requirement for all Aetna commercial plans.