C9789 Instill pharm renal pelvis

Instillation of anti-neoplastic pharmacologic/biologic agent into renal pelvis, any method, including all imaging guidance, including volumetric measurement if performed

Medically Unlikely Edits (effective October 1, 2026)

Payer policies and prior authorization for C9789

Payer coverage policies that name C9789

C9789 appears in 2 coverage policies from Aetna, Premera Blue Cross.

PayerPolicyRole in policyReviewedDocument
AetnaMitomycin Pyelocalyceal Solution (Jelmyto) (0972)listed, no stanceAug 13, 2025payer document
Premera Blue CrossNon-covered Experimental/Investigational Services
Page | 31 of 38 | ∞		listed, no stanceOct 1, 2026payer document

Medicaid fee-for-service

  • AZ: $367.59 (asc), effective Oct 1, 2026
  • IN: $0.00 (professional, facility), effective Oct 1, 2023
  • KS: $0.00 (asc, facility), effective Oct 1, 2023
  • KY: $655.81 (asc), effective Jan 1, 2026
  • MA: $1041.46 (asc), effective May 1, 2026
  • ND: $386.60 (physician, facility), effective Aug 1, 2026
  • VT: $0.00 (outpatient_hospital_opps), effective Feb 1, 2026
  • WY: $541.29 (outpatient_hospital_apc, Ambulatory Surgical Centers), effective Apr 1, 2026

From payers' published prior-auth lists, coverage policies and state Medicaid fee schedules, updated Oct 16, 2026. The role is what the policy's own code table or text says about the code. Not a guarantee of coverage or payment; verify with the payer. CPT® is a registered trademark of the American Medical Association.