TL;DR: Aetna, a CVS Health company, modified CPB 1020 covering sodium thiosulfate (Pedmark) on December 10, 2025. If your team bills J0208 for Pedmark or J9060 for cisplatin in pediatric oncology cases, this coverage policy update applies to you now.
Aetna CPB 1020 Aetna system covers sodium thiosulfate (Pedmark) — billed under HCPCS J0208 — to reduce cisplatin-induced hearing loss in pediatric patients. The criteria are tight, and the prior authorization requirement is non-negotiable. Here's what your billing team needs to know before submitting claims.
Quick-Reference: Aetna Sodium Thiosulfate (Pedmark) Coverage Policy — CPB 1020
| Field | Detail |
|---|---|
| Payer | Aetna, a CVS Health company |
| Policy | Sodium Thiosulfate (Pedmark) — CPB 1020 |
| Policy Code | CPB 1020 |
| Change Type | Modified |
| Effective Date | December 10, 2025 |
| Impact Level | High |
| Specialties Affected | Pediatric Oncology, Hematology/Oncology, Infusion Centers, Hospital Outpatient |
| Key Action | Verify precertification is in place before billing J0208 for any Pedmark administration — missing prior auth means denial |
Aetna Sodium Thiosulfate Coverage Criteria and Medical Necessity Requirements 2025
The Aetna sodium thiosulfate coverage policy under CPB 1020 is narrow by design. That's not a criticism — it reflects the FDA label. But narrow criteria mean more room for claim denial if your team misses a detail on the prior auth submission.
Aetna considers Pedmark medically necessary for pediatric members who are at least one month old. Two conditions must both be true. First, the member must be receiving cisplatin (billed as J9060) to treat a localized, non-metastatic solid tumor. Second, the cisplatin infusion must run six hours or less.
Both criteria are required — not one or the other. If the cisplatin infusion is scheduled longer than six hours, Pedmark will not be covered. That infusion duration gate is the single most common clinical detail that gets missed on precertification requests.
On the Pedmark billing side, J0208 (injection, sodium thiosulfate, 100 mg) is the covered HCPCS code. You'll also bill CPT 96365 for the IV infusion administration. Make sure your charge capture links J0208 and CPT 96365 to the appropriate diagnosis codes from the malignant solid tumor range — the ICD-10 codes span C00.0 through D09.9, with specific C90.x codes carved out. More on that in the code table below.
Prior authorization is required for all Aetna participating providers and members in applicable plan designs. No exceptions. Call (866) 752-7021 or fax the precertification request to (888) 267-3277. For the Statement of Medical Necessity form, Aetna directs providers to their Specialty Pharmacy Precertification page. Build that step into your workflow before the drug is ordered — not after.
Aetna Sodium Thiosulfate Exclusions and Non-Covered Indications
Aetna's position on off-label or expanded use of Pedmark is unambiguous. Any indication outside the two criteria above is classified as experimental, investigational, or unproven.
That means: metastatic tumors are not covered. Cisplatin infusions longer than six hours are not covered. Adult patients are not covered. Any diagnosis outside a localized, non-metastatic solid tumor is not covered.
If you're treating a pediatric patient with cisplatin for a metastatic solid tumor and you submit J0208, expect a denial. The diagnosis code matters here. ICD-10 codes for metastatic disease fall outside the covered range. Your clinical and billing teams need to align on this before submitting.
Coverage Indications at a Glance
| Indication | Status | Relevant Codes | Notes |
|---|---|---|---|
| Pediatric patient (≥1 month), cisplatin for localized non-metastatic solid tumor, infusion ≤6 hours | Covered | J0208, J9060, CPT 96365, C00.0–D09.9 (solid tumor range) | Prior authorization required; both criteria must be met |
| Cisplatin infusion duration longer than 6 hours | Not Covered | J0208 | Does not meet medical necessity criteria under CPB 1020 |
| Metastatic solid tumor diagnoses | Not Covered | J0208 | Outside covered ICD-10 range for this indication |
| Adult patients (18+) | Not Covered | J0208 | Policy limited to pediatric members ≥1 month of age |
| Any other indication for sodium thiosulfate | Experimental / Investigational | J0208 | Aetna considers all other uses unproven |
| Continuation of therapy (existing or new members) | Covered | J0208, J9060, CPT 96365 | Must meet all initial criteria; reauthorization required |
Aetna Sodium Thiosulfate Billing Guidelines and Action Items 2025
This policy was modified on December 10, 2025. If your team has active Pedmark cases or expects new starts, work through these steps now.
| # | Action Item |
|---|---|
| 1 | Confirm prior auth status on every active Pedmark case before billing. Call (866) 752-7021 to verify. Billing J0208 without an approved authorization is the fastest path to a claim denial that won't overturn on appeal. |
| 2 | Update your charge capture to link J0208 with CPT 96365. Pedmark is administered as an IV infusion. If your system doesn't automatically pair the drug code with the administration code, claims will be incomplete. Check your infusion center charge master. |
| 3 | Verify the cisplatin infusion duration is documented as six hours or less in the medical record. This is a hard stop in the coverage policy. If the order says eight hours, the authorization won't come through. Your precertification team needs this documentation from the ordering oncologist before submitting. |
| 4 | Confirm the diagnosis is a localized, non-metastatic solid tumor. Pull the ICD-10 from the oncology note — not from the problem list. Use codes from the C00.0–D09.9 range covered under CPB 1020. If there's any staging ambiguity, your billing team and the ordering physician need to align before the auth request goes in. |
| 5 | Use T45.1X5A–T45.1X5S when coding for cisplatin adverse effects. These ICD-10 codes cover adverse effects of antineoplastic drugs including cisplatin. They're relevant when the ototoxicity risk is the clinical driver for Pedmark and may support your medical necessity documentation. |
| 6 | Submit the Statement of Medical Necessity form with every new precertification. Aetna's Specialty Pharmacy Precertification page has the current SMN forms. Make sure your clinical staff is using the updated version — outdated forms slow down authorization. |
| 7 | Set a reauthorization reminder for continuation of therapy cases. Aetna requires that continuation requests meet all initial criteria. That includes new members requesting authorization mid-treatment. Don't assume an existing auth carries forward without review. |
If you're billing Pedmark across a high volume of pediatric oncology cases, talk to your compliance officer before December 10, 2025 to confirm your precertification workflow matches what this modified policy requires.
| Previous Version | Current Version |
|---|---|
| Coverage is considered experimental and investigational for all indications | Coverage is considered medically necessary when specific criteria are met |
| Prior authorization is not required | Prior authorization is required for initial treatment |
| Documentation must include clinical history | Documentation must include clinical history |
| Re-review every 24 months | Re-review every 12 months with updated clinical documentation |
CPT, HCPCS, and ICD-10 Codes for Sodium Thiosulfate (Pedmark) Under CPB 1020
Covered HCPCS Codes (When Selection Criteria Are Met)
| Code | Type | Description |
|---|---|---|
| J0208 | HCPCS | Injection, sodium thiosulfate, 100 mg |
Other CPT and HCPCS Codes Related to CPB 1020
These codes appear in the policy and are relevant to Pedmark billing, though coverage depends on clinical context.
| Code | Type | Description |
|---|---|---|
| CPT 96365 | CPT | Intravenous infusion, for therapy, prophylaxis, or diagnosis; initial |
| J9060 | HCPCS | Injection, cisplatin, powder or solution, 10 mg |
CPT 96365 is the administration code you'll bill alongside J0208 for the Pedmark infusion. J9060 covers the cisplatin itself — that's the concurrent chemotherapy triggering Pedmark's use and should already be in your charge capture for these cases.
Key ICD-10-CM Diagnosis Codes
These are the codes listed under CPB 1020. Use them to document the covered indications and link diagnosis to the J0208 claim line.
| Code | Description |
|---|---|
| C00.0–C90.02 | Malignant solid tumors |
| C90.20 | Malignant solid tumors |
| C90.21 | Malignant solid tumors |
| C90.22 | Malignant solid tumors |
| C90.23 | Malignant solid tumors |
| C90.24 | Malignant solid tumors |
| C90.25 | Malignant solid tumors |
| C90.26 | Malignant solid tumors |
| C90.27 | Malignant solid tumors |
| C90.28 | Malignant solid tumors |
| C90.29 | Malignant solid tumors |
| C90.30 | Malignant solid tumors |
| C90.31 | Malignant solid tumors |
| C90.32 | Malignant solid tumors |
| C96.0–D09.9 | Malignant solid tumors |
| T45.1X5A–T45.1X5S | Adverse effect of antineoplastic and immunosuppressive drugs (cisplatin) |
The T45.1X5A–T45.1X5S range is worth flagging specifically. These codes document the adverse effect of cisplatin — which is exactly what Pedmark is administered to prevent. Including the appropriate code from this range in your medical necessity documentation strengthens the clinical justification for Pedmark reimbursement.
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