All Insurance Policy Changes (Page 4)

Continuing from page 3. Showing older policy changes tracked across all payers. Use the filters in the related-hubs section below to narrow by provider, state, or specialty.

High impact
Eptinezumab-jjmr (Vyepti) (CPB 0970, reviewed 2025-12-09)
Aetna·Effective Dec 9, 2025
Aetna has updated its clinical policy for eptinezumab-jjmr (Vyepti), a CGRP monoclonal antibody for migraine prevention. The policy requires precertification for all uses, mandates a minimum of 3 months of treatment before initial approval, and requires documented reduction in migraine days per month for continuation therapy. Billing teams must implement prior authorization workflows and ensure proper coding with HCPCS code J3032 paired with IV infusion CPT codes.
Medium impact
Plasminogen, Human-tvmh (Ryplazim) (CPB 0976, reviewed 2026-02-17)
Aetna·Effective Feb 17, 2026
Aetna has established coverage criteria for Ryplazim (plasminogen, human-tvmh) for treatment of plasminogen deficiency type 1. The policy requires precertification for all claims, prescriber consultation with a hematologist, baseline plasminogen activity ≤45%, and documented clinical symptoms. All other indications are considered experimental/investigational.
High impact
Plasmapheresis/Plasma Exchange/Therapeutic Apheresis (CPB 0285, reviewed 2026-04-16)
Aetna·Effective Apr 16, 2026
Aetna's Plasmapheresis/Plasma Exchange/Therapeutic Apheresis policy (CPB 0285) has been reviewed and updated as of April 16, 2026. This policy establishes comprehensive medical necessity criteria for plasmapheresis and therapeutic apheresis procedures across 40+ approved indications while designating numerous other conditions as experimental/investigational. Billing teams must ensure claims align with the specific approved indications listed and deny or obtain additional information for unlisted conditions.
High impact
Physical Therapy (CPB 0325, reviewed 2026-06-02)
Aetna·Effective Jun 2, 2026
Aetna updated its Physical Therapy Clinical Policy Bulletin (CPB 0325) effective June 2, 2026, clarifying medical necessity criteria, explicitly listing experimental/unproven therapies that are not covered (including kinesio taping, blood flow restriction therapy, virtual reality gait training, and others), and reinforcing documentation requirements. Billing teams must deny claims for listed experimental modalities and ensure PT authorization is based on documented functional improvement within one month or establishment of a home maintenance program.
Medium impact
Pillows and Cushions (CPB 0456, reviewed 2026-07-09)
Aetna·Effective Jul 9, 2026
Aetna's updated policy (CPB 0456, effective 2026-07-09) clarifies that most therapeutic pillows and cushions are NOT covered DME because they lack durability and are not primarily medical in nature. Covers only cushions integral to other DME (e.g., wheelchair seat cushions) or specialized support surfaces for decubitus ulcer prevention/treatment. MedCline Positioning Device remains experimental/investigational. Requires Standard Written Orders (SWO) with specific elements before supplier billing.
High impact
Phototherapy for Acne (CPB 0656, reviewed 2025-10-03)
Aetna·Effective Oct 3, 2025
Aetna has updated CPB 0656 to classify most phototherapy and laser treatments for acne as experimental, investigational, or unproven and therefore non-covered. This includes popular treatments like AviClear Laser, blue light therapy, PDT systems, LED therapy, intense pulsed light, and home-based light devices. Billing teams must immediately deny or obtain prior authorization denials for these procedures and update system rules to prevent claim submissions.
High impact
Erythropoiesis Stimulating Agents (CPB 0195, reviewed 2026-01-20)
Aetna·Effective Jan 20, 2026
Aetna has updated its Erythropoiesis Stimulating Agents (ESA) policy effective January 20, 2026, reinforcing precertification requirements for five ESA drugs (Aranesp, Epogen, Procrit, Retacrit, Mircera) and clarifying coverage criteria including hemoglobin thresholds, iron sufficiency requirements, and contraindications with HIF-PHI drugs. All ESA requests now require prior authorization before dispensing.
High impact
Etanercept (CPB 0315, reviewed 2026-07-08)
Aetna·Effective Jul 8, 2026
Aetna has updated its Clinical Policy Bulletin 0315 for Etanercept (Enbrel) effective immediately, establishing comprehensive prior authorization criteria across multiple rheumatologic, dermatologic, and oncologic conditions. The policy specifies prescriber specialty requirements, biomarker testing mandates, prior treatment failure documentation, and disease activity thresholds that must be met before coverage approval. Billing teams must implement these authorization requirements across all affected indications to prevent claim denials.
High impact
Esketamine (Spravato) (CPB 0950, reviewed 2026-02-25)
Aetna·Effective Feb 25, 2026
Aetna updated its Esketamine (Spravato) coverage policy (CPB 0950) effective February 25, 2026, establishing new clinical criteria for coverage of this nasal spray for treatment-resistant depression (TRD) and major depressive disorder with acute suicidal ideation. The policy requires mandatory precertification for all administrations, specifies that treatment must be psychiatrist-prescribed and provider-supervised with 2-hour post-administration monitoring, and limits continuation therapy to 6 months for TRD and 4 weeks for acute suicidal ideation cases. Billing teams must implement prior authorization workflows and ensure proper documentation of clinical criteria at point of service.
High impact
Evinacumab-dgnb (Evkeeza) (CPB 0989, reviewed 2026-04-10)
Aetna·Effective Apr 10, 2026
Aetna has released a new clinical policy for evinacumab-dgnb (Evkeeza) effective immediately for treating homozygous familial hypercholesterolemia (HoFH) in members age 1 and older. The policy requires precertification for all claims, specialist prescribing (cardiologist, endocrinologist, lipid specialist, geneticist), and strict clinical criteria including genetic confirmation of HoFH and prior optimization with lipid-lowering therapies based on age group.
High impact
Exagamglogene Autotemcel (Casgevy) (CPB 1052, reviewed 2025-12-31)
Aetna·Effective Jan 1, 2025
Aetna has established a new clinical policy (CPB 1052) for Casgevy (exagamglogene autotemcel), a gene therapy for sickle cell disease and transfusion-dependent beta-thalassemia in patients 12+. The policy requires precertification through National Medical Excellence (NME), mandates administration at Aetna Institutes GCIT Network facilities, and specifies strict clinical criteria including failed hydroxyurea trials, HSCT ineligibility/no matched donor, and multiple clinical exclusions. This is a brand-new policy effective immediately with mandatory prior authorization workflows.
Medium impact
Erectile Dysfunction and Peyronie's Disease (CPB 0007, reviewed 2026-07-29)
Aetna·Identified Aug 13, 2026
This is Aetna's Clinical Policy Bulletin 0007 (reviewed 2026-07-29) establishing medical necessity criteria for erectile dysfunction and Peyronie's disease diagnosis and treatment. The policy clarifies covered diagnostic procedures, laboratory tests, medications, devices, and surgical interventions, while designating certain tests and treatments as experimental/investigational. Billing teams must ensure claims align with these specific coverage criteria to avoid denials.
High impact
Extended-Release Buprenorphine Injectables (CPB 0910, reviewed 2025-12-30)
Aetna·Effective Dec 30, 2025
Aetna has updated its medical policy on extended-release buprenorphine injectables (CPB 0910), establishing coverage criteria for Sublocade and Brixadi for moderate-to-severe opioid use disorder treatment. Sublocade is now covered when patients have stabilized on transmucosal buprenorphine for a minimum of 7 days and are enrolled in a comprehensive treatment program; Brixadi is covered for patients initiating or already on buprenorphine treatment. All other indications remain experimental/investigational.
High impact
Pharmacogenetic and Pharmacodynamic Testing (CPB 0715, reviewed 2025-12-03)
Aetna·Effective Dec 3, 2025
Aetna updated its pharmacogenetic and pharmacodynamic testing policy (CPB 0715) to define medical necessity for specific genetic tests tied to targeted cancer therapies and other precision medicine treatments. The policy explicitly identifies which testing panels are medically necessary (e.g., ALK fusion testing for crizotinib) and which are NOT (e.g., FoundationOne CDx for ALK-positive NSCLC). Billing teams must verify test medical necessity against this policy before processing claims to avoid denials.
High impact
Eladocagene Exuparvovec-tneq (Kebilidi) (CPB 1073, reviewed 2026-03-27)
Aetna·Effective Mar 27, 2026
Aetna has established a new Clinical Policy Bulletin (CPB 1073) for Kebilidi (eladocagene exuparvovec-tneq), a gene therapy for aromatic L-amino acid decarboxylase (AADC) deficiency in pediatric patients aged 16 months to 10 years. This policy requires mandatory precertification, restricts treatment to Aetna Institutes GCIT Network facilities, and establishes strict clinical criteria including specific CSF metabolite profiles, genetic confirmation, and neurological assessments. Billing teams must implement precertification workflows immediately and ensure all related diagnostic testing and surgical codes are properly coordinated.
Medium impact
Electric Tumor Treatment Fields (CPB 0827, reviewed 2026-02-18)
Aetna·Effective Feb 18, 2026
Aetna has established formal medical necessity criteria for Electric Tumor Treatment Fields (ETTF) therapy coverage, limited to newly diagnosed supratentorial glioblastoma (WHO grade IV astrocytoma) in patients aged 22+ who meet specific clinical and performance requirements. The policy explicitly designates ETTF for all other malignant tumors and non-temozolomide combination therapies as experimental/investigational and not covered. Billing teams must implement prior authorization controls and ensure claims only proceed when all 8 selection criteria are documented and met.
High impact
Endovascular Arterial and Venous Stent Procedures (CPB 0785, reviewed 2026-06-05)
Aetna·Effective Jun 5, 2026
Aetna updated its Clinical Policy Bulletin 0785 for endovascular arterial and venous stent procedures effective June 5, 2026. The policy clarifies medical necessity criteria for stent procedures across peripheral vascular, central venous, and visceral sites, with specific coverage for FDA-approved stents under defined clinical scenarios and explicit exclusions for experimental approaches like biodegradable stents and certain off-label applications. Billing teams must align claim submissions with the specific indications and device requirements outlined, particularly noting that prior authorization through EviCore by Evernorth Peripheral Vascular Intervention Clinical Guidelines is required.
High impact
Peripheral Electrical Nerve Stimulation for Pain (CPB 0011, reviewed 2026-06-03)
Aetna·Effective Jun 3, 2026
Aetna updated its peripheral electrical nerve stimulation policy (CPB 0011) effective June 3, 2026, clarifying coverage criteria for TENS, PENS, and implantable nerve stimulators. Key changes include strict trial period requirements (1-2 months for TENS), specific documentation standards, a limit of two CPT 64555 procedures per 365 days for implantable systems, and expanded exclusions for experimental indications (e.g., genicular nerve stimulation for knee pain, occipital neuralgia). Billing teams must update authorization workflows and claims validation immediately.
Medium impact
Elivaldogene Autotemcel (Skysona) (CPB 1017, reviewed 2026-04-08)
Aetna·Effective Apr 8, 2026
Aetna has issued a new Clinical Policy Bulletin (CPB 1017, effective 2026-04-08) establishing coverage criteria for Skysona (elivaldogene autotemcel), a gene therapy for early active cerebral adrenoleukodystrophy (CALD) in boys ages 4-17. This is a specialized therapy requiring precertification, administration at designated Aetna Institutes GCIT Network facilities, and compliance with strict clinical and laboratory eligibility criteria. Billing teams must implement precertification requirements and ensure only qualifying patients are billed for this high-cost therapy.
Medium impact
Percutaneous Transluminal Septal Myocardial Ablation (PTSMA) (CPB 0558, reviewed 2026-02-19)
Aetna·Effective Feb 19, 2026
Aetna has issued a fresh clinical policy (CPB 0558, reviewed 2026-02-19) establishing medical necessity criteria for Percutaneous Transluminal Septal Myocardial Ablation (PTSMA) in adults and young patients with hypertrophic obstructive cardiomyopathy. The policy covers CPT 93583 when strict selection criteria are met, but designates ultrasound-guided PTSMA and SESAME procedures as experimental/investigational and not covered. Billing teams must immediately verify patient eligibility against the detailed clinical criteria before submitting claims.
High impact
Elotuzumab (Empliciti) (CPB 0899, reviewed 2026-03-02)
Aetna·Effective Mar 2, 2026
Aetna has updated its Clinical Policy Bulletin 0899 for Elotuzumab (Empliciti), effective immediately. The policy requires precertification for all elotuzumab claims on commercial medical plans and covers the drug only for previously treated multiple myeloma (in combination with lenalidomide/dexamethasone, bortezomib/dexamethasone, or pomalidomide/dexamethasone) and specific plasma cell disorders (POEMS, MIDD, MGRS). All other indications remain experimental/investigational and are not covered.
High impact
Elranatamab-bcmm (Elrexfio) (CPB 1040, reviewed 2025-12-10)
Aetna·Effective Dec 10, 2025
Aetna has established a new coverage policy for elranatamab-bcmm (Elrexfio), a bispecific T-cell engager for relapsed or refractory multiple myeloma. The policy requires precertification for all commercial plans and limits coverage to patients who have received at least 4 prior therapies including specific drug classes (anti-CD38 monoclonal antibody, proteasome inhibitor, and immunomodulatory agent). Billing teams must implement prior authorization requirements and update systems to reflect the specific dosing schedules and eligibility criteria.
Medium impact
Emapalumab-lzsg (Gamifant) (CPB 0948, reviewed 2025-12-08)
Aetna·Effective Dec 8, 2025
Aetna has updated its clinical policy for Emapalumab-lzsg (Gamifant) to establish coverage criteria for treatment of primary hemophagocytic lymphohistiocytosis (HLH) and macrophage activation syndrome (MAS) in Still's disease. Billing teams must implement prior authorization requirements and ensure proper TB screening documentation before claims can be processed. This is a new or significantly revised policy (reviewed 2025-12-08) affecting a specialty injectable medication with specific patient eligibility and pre-treatment requirements.
Medium impact
Enuresis (CPB 0431, reviewed 2026-07-01)
Aetna·Effective Jul 1, 2026
Aetna updated its enuresis treatment policy (CPB 0431, effective 2026-07-01) to establish specific medical necessity criteria for bedwetting alarms and desmopressin in children 7 years and older. The policy designates numerous alternative therapies (acupuncture, adenoidectomy, tonsillectomy, hypnosis, chiropractic, TENS, clonidine, and others) as experimental/investigational and not covered. Billing teams must immediately halt claims for non-covered procedures and enforce strict documentation requirements for covered treatments.
Medium impact
Enfuvirtide (Fuzeon) (CPB 0671, reviewed 2026-03-25)
Aetna·Effective Mar 25, 2026
Aetna updated its Enfuvirtide (Fuzeon) medical policy (CPB 0671) effective 2026-03-25, clarifying coverage criteria for HIV-1 treatment in treatment-experienced patients with documented viremia, resistance, or intolerance. The policy explicitly excludes treatment-naïve patients and COVID-19 indications as experimental/investigational. Billing teams must verify prior authorization requirements and ensure claims include proper documentation of treatment history and virologic response.

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Archive by year

2023 2024 2025 2026

Eptinezumab-jjmr (Vyepti) (CPB 0970, reviewed 2025-12-09)

Plasminogen, Human-tvmh (Ryplazim) (CPB 0976, reviewed 2026-02-17)

Plasmapheresis/Plasma Exchange/Therapeutic Apheresis (CPB 0285, reviewed 2026-04-16)

Physical Therapy (CPB 0325, reviewed 2026-06-02)

Pillows and Cushions (CPB 0456, reviewed 2026-07-09)

Phototherapy for Acne (CPB 0656, reviewed 2025-10-03)

Erythropoiesis Stimulating Agents (CPB 0195, reviewed 2026-01-20)

Etanercept (CPB 0315, reviewed 2026-07-08)

Esketamine (Spravato) (CPB 0950, reviewed 2026-02-25)

Evinacumab-dgnb (Evkeeza) (CPB 0989, reviewed 2026-04-10)

Exagamglogene Autotemcel (Casgevy) (CPB 1052, reviewed 2025-12-31)

Erectile Dysfunction and Peyronie's Disease (CPB 0007, reviewed 2026-07-29)

Extended-Release Buprenorphine Injectables (CPB 0910, reviewed 2025-12-30)

Pharmacogenetic and Pharmacodynamic Testing (CPB 0715, reviewed 2025-12-03)

Eladocagene Exuparvovec-tneq (Kebilidi) (CPB 1073, reviewed 2026-03-27)

Electric Tumor Treatment Fields (CPB 0827, reviewed 2026-02-18)

Endovascular Arterial and Venous Stent Procedures (CPB 0785, reviewed 2026-06-05)

Peripheral Electrical Nerve Stimulation for Pain (CPB 0011, reviewed 2026-06-03)

Elivaldogene Autotemcel (Skysona) (CPB 1017, reviewed 2026-04-08)

Percutaneous Transluminal Septal Myocardial Ablation (PTSMA) (CPB 0558, reviewed 2026-02-19)

Elotuzumab (Empliciti) (CPB 0899, reviewed 2026-03-02)

Elranatamab-bcmm (Elrexfio) (CPB 1040, reviewed 2025-12-10)

Emapalumab-lzsg (Gamifant) (CPB 0948, reviewed 2025-12-08)

Enuresis (CPB 0431, reviewed 2026-07-01)

Enfuvirtide (Fuzeon) (CPB 0671, reviewed 2026-03-25)