Mitomycin Pyelocalyceal Solution (Jelmyto) - 0972 — CPB 0972 | AETNA Coverage Update

Aetna modified CPB 0972 for mitomycin pyelocalyceal solution (Jelmyto), effective September 26, 2025. Here's what billing teams need to know before claims go out.

Aetna, a CVS Health company, updated its Jelmyto coverage policy under CPB 0972 in the Aetna mitomycin pyelocalyceal solution coverage policy. The update covers instillation of mitomycin (Jelmyto) for upper tract urothelial cancer — a specialty drug billed under HCPCS J9281 and administered via CPT 50391 or 52005. If your urology or oncology practice bills Aetna commercial plans for this drug, precertification is not optional. It's required across all applicable plan designs, and missing it means a claim denial before you even get to medical necessity.

Quick-Reference Table

Aetna Jelmyto Coverage Criteria and Medical Necessity Requirements 2025

The real issue with Jelmyto billing under Aetna is that this drug sits at the intersection of specialty pharmacy and medical benefit — and that creates more friction than most teams expect.

Jelmyto (mitomycin) is a reverse thermal gel used for non-invasive treatment of low-grade upper tract urothelial cancer (UTUC). The diagnoses in scope span malignant neoplasms of the renal pelvis (C65.1–C65.9), ureter (C66.1–C66.9), and kidney (C64.1–C64.9). That's 27 ICD-10-CM codes total, and the right one on your claim matters. C65 codes — renal pelvis — are your primary target here. C66 codes for ureter and C64 codes for kidney also fall within the policy's scope.

Aetna's Jelmyto coverage policy requires precertification for all Aetna participating providers and members in applicable plan designs. There are no exceptions for "established" patients or prior-approved courses of treatment. Every new treatment course needs to go through prior authorization before the first instillation.

Medical necessity documentation needs to support the specific diagnosis. Aetna will look for confirmation that the cancer is low-grade and upper tract, that the patient is a surgical candidate or that nephron-sparing treatment is appropriate, and that the administration method matches what you're billing. A precertification that doesn't align with the procedure code you submit is just as problematic as no precertification at all.

For Medicare criteria, CPB 0972 explicitly redirects to Aetna's Medicare Part B criteria — this commercial policy does not govern Medicare claims. If your practice sees both commercial Aetna and Aetna Medicare Advantage patients, don't apply the same prior auth workflow to both populations without checking the Medicare-specific path.

Coverage Indications at a Glance

Aetna Jelmyto Billing Guidelines and Action Items 2025

Jelmyto billing fails in predictable places. Here's how to get ahead of each one before your next claim goes out.

CPT, HCPCS, and ICD-10 Codes for Mitomycin Pyelocalyceal Solution Under CPB 0972

HCPCS Codes — Covered When Selection Criteria Are Met

Other CPT and HCPCS Codes Related to CPB 0972

These codes are associated with the procedure and facility billing but are not the primary drug code. They must align with your precertification.

Key ICD-10-CM Diagnosis Codes Under CPB 0972

One more thing worth flagging on the code list: the ICD-10 descriptions in Aetna's published policy repeat the same generic label across multiple codes in each category. That's almost certainly a display artifact in the source document — your encoder or billing system will have the laterality-specific descriptions. Use your encoder to confirm the correct descriptor for each code before it goes on a claim. Don't copy the abbreviated descriptions above directly into your charge capture.