CommercialPrior AuthMedium impact
Nogapendekin Alfa Inbakicept-pmln (Anktiva) (CPB 1059, reviewed 2025-12-10)
Aetna·Urology, Oncology·Medical Policy
Effective date
Aug 1, 2024
We identified it
Aug 18, 2026
Summary
Aetna has established a new medical policy (CPB 1059, effective August 1, 2024) covering Anktiva (nogapendekin alfa inbakicept-pmln) for BCG-unresponsive non-muscle invasive bladder cancer with carcinoma in situ. All uses require precertification before treatment begins. Billing teams must implement prior authorization workflows and ensure claims are submitted with appropriate diagnosis and procedure codes.
Action Required
By December 31, 2024: Billing team must implement precertification requirements for all Anktiva claims. (1) Update billing software to flag all claims with HCPCS J9028 for mandatory prior authorization before claim submission. (2) Configure system to route all Anktiva requests to Aetna precertification at (866) 752-7021 or fax (888) 267-3277. (3) Create internal checklist requiring verification that patient has BCG-unresponsive NMIBC with CIS (ICD-10: C67.0-C67.9 or D09.0) before approving claims. (4) Train providers to submit Statement of Medical Necessity (SMN) forms with initial authorization requests. (5) Update encounter templates to document maintenance dosing schedule (months 4, 7, 10, 13, 19, and potentially 25, 31, 37). (6) Establish reauthorization process for continuation beyond month 37 (maximum 37 months treatment). Consequence: Claims submitted without valid precertification will be denied by Aetna.