CommercialPrior AuthMedium impact
Mitomycin Pyelocalyceal Solution (Jelmyto) (CPB 0972, reviewed 2026-10-14)
Aetna·Urology, Oncology·Medical Policy
We identified it
Oct 19, 2026
Summary
Aetna's Clinical Policy Bulletin 0972 establishes coverage criteria for Jelmyto (mitomycin pyelocalyceal solution) for treating non-metastatic, low-grade, low-volume upper tract urothelial cancer. The policy requires precertification for all Aetna participating providers and members, limits initial approval to 6 weekly doses, and allows up to 11 additional monthly doses for patients achieving complete response at 3 months. This is a medical necessity policy with specific dosage, administration route, and patient eligibility requirements.
Action Required
Billing team must implement the following precertification workflow for Aetna commercial medical plans: (1) Require all participating providers to obtain precertification before administering Jelmyto by calling (866) 752-7021 or faxing (888) 267-3277; (2) Submit Statement of Medical Necessity (SMN) precertification forms (available through Aetna's Specialty Pharmacy Precertification portal); (3) Verify that initial requests are limited to 6 weekly doses for eligible patients (non-metastatic, low-grade, low-volume upper tract urothelial cancer, 5-15 mm tumors); (4) For continuation therapy, verify complete response documentation (urine cytology and ureteroscopy confirming complete absence of tumors at 3 months) before authorizing up to 11 additional monthly maintenance doses; (5) Ensure claims are submitted with correct HCPCS code J9281 (mitomycin pyelocalyceal instillation, 1 mg) along with applicable CPT codes (50391 or 52005) and ICD-10 diagnosis codes (C64.1-C66.9); (6) Flag claims for denial if precertification was not obtained, as this policy requires precertification of all applicable requests. Update billing system templates and prior authorization checklists to reflect these requirements.