CommercialPrior AuthMedium impact
Gemcitabine Intravesical System (Inlexzo) (CPB 1095, reviewed 2026-09-14)
Aetna·Oncology, Urology·Medical Policy
Effective date
Feb 20, 2026
We identified it
Oct 2, 2026
Summary
Aetna has established a new medical policy (CPB 1095, effective 02/20/2026) covering gemcitabine intravesical system (Inlexzo) for BCG-unresponsive non-muscle invasive bladder cancer. The policy requires precertification for all claims, specifies coverage criteria including high-risk disease status and BCG-unresponsiveness, and establishes a defined dosing schedule (8 doses every 3 weeks, then 6 doses every 12 weeks). Billing teams must implement precertification requirements and use HCPCS code J9183 when criteria are met.
Action Required
By February 20, 2026: (1) Billing team must configure billing system to require precertification for HCPCS code J9183 (gemcitabine intravesical system) for all Aetna commercial members. (2) Create precertification routing in billing system: direct all J9183 requests to Aetna Specialty Pharmacy Precertification at phone (866) 752-7021 or fax (888) 267-3277. (3) Update claim submission protocols to ensure precertification numbers are captured and attached to all J9183 claims; claims submitted without precertification authorization will be denied. (4) Verify provider documentation includes: diagnosis code (C67.0-C67.9 for malignant neoplasm of bladder or D09.0 for carcinoma in situ), confirmation of high-risk disease status, confirmation of BCG-unresponsiveness, and intended dosing schedule (8 doses every 3 weeks for 6 months, then 6 doses every 12 weeks). (5) Educate urology/oncology providers and clinical staff on coverage requirements and precertification process. (6) Update encounter templates and billing software decision trees to reflect the 14-dose maximum lifetime limit per policy.