All Insurance Policy Changes (Page 5)

Continuing from page 4. 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
Percutaneous Mitral Valve and Tricuspid Valve Repair (CPB 0880, reviewed 2026-06-05)
Aetna·Effective Jun 5, 2026
Aetna has updated its coverage policy (CPB 0880) for percutaneous mitral and tricuspid valve repair procedures. The policy clearly defines which interventions are medically necessary (MitraClip for chronic mitral regurgitation and mitral valve-in-valve replacement) versus those considered experimental/investigational. Critical change: Tricuspid valve repair procedures and several mitral valve repair approaches remain non-covered/investigational, and claims for these procedures will be denied.
Medium impact
Penpulimab-kcqx (CPB 1080, reviewed 2026-04-15)
Aetna·Effective Apr 15, 2026
Aetna has established new coverage criteria for penpulimab-kcqx (CPB 1080), a PD-1 blocking antibody approved for nasopharyngeal carcinoma and appendiceal neoplasms. Precertification is now required for all claims, with specific dosing protocols (200 mg IV every 3 weeks or every 2 weeks depending on indication) and a maximum 24-month treatment duration. Patients with prior disease progression on PD-1/PD-L1 inhibitors are excluded from coverage.
High impact
Pembrolizumab Products (Keytruda and Keytruda Qlex) (CPB 0890, reviewed 2026-07-14)
Aetna·Effective Jul 14, 2026
Aetna has updated its clinical policy for Pembrolizumab (Keytruda and Keytruda Qlex) effective immediately, establishing comprehensive coverage criteria across multiple cancer indications with specific molecular markers (MSI-H, dMMR, TMB-H, PD-L1 status). The policy mandates precertification for all uses and applies site-of-care utilization management. Key exclusions include pediatric patients with TMB-H CNS cancers and members with prior PD-1/PD-L1 inhibitor progression (with limited exceptions).
Medium impact
Pelvic Congestion Syndrome Treatments (CPB 0441, reviewed 2026-07-09)
Aetna·Effective Jul 9, 2026
Aetna's updated Clinical Policy Bulletin 0441 (effective 2026-07-09) establishes coverage criteria for pelvic congestion syndrome treatments, covering gonadal/ovarian vein embolization ONLY when patients have definitive diagnostic imaging (CT/MRI/venography) AND have failed appropriate pharmacotherapy. Median sacral vein embolization, sacral nerve neuromodulation, ovarian vein transposition, and micronized purified flavonoid fraction remain non-covered as experimental/investigational. Billing teams must verify both criteria are met before authorizing claims.
Medium impact
Diphtheria, Tetanus, and Pertussis Vaccines (CPB 0653, reviewed 2025-12-08)
Aetna·Identified Aug 13, 2026
Aetna has reaffirmed its medical necessity coverage for diphtheria, tetanus, and pertussis vaccines across multiple formulations (DTaP, Tdap, and combination vaccines) for eligible age groups and clinical scenarios, including booster immunization in adults 10+ years, pregnant women, and post-partum women. This policy establishes specific CPT codes for each vaccine formulation and includes coverage for tetanus toxoid-containing immunizations for wound treatment. The policy applies nationally and affects pediatric, adult, and preventive care billing.
Medium impact
Pegvaliase-pqpz (Palynziq) (CPB 0933, reviewed 2026-06-09)
Aetna·Effective Jun 9, 2026
Aetna has issued a new clinical policy (CPB 0933, effective 2026-06-09) establishing coverage criteria for Pegvaliase-pqpz (Palynziq) in treating phenylketonuria (PKU). The policy requires patients to be 12+ years old with confirmed PKU diagnosis and baseline blood phenylalanine >600 micromol/L, must be prescribed by metabolic disease/PKU specialists, and requires documented clinical response or continued titration for coverage continuation. Prior to this policy, coverage criteria for this medication may have been unclear or absent.
High impact
Donanemab-azbt (Kisunla) (CPB 1066, reviewed 2025-10-17)
Aetna·Effective Oct 17, 2025
Aetna has established new medical necessity criteria for Donanemab-azbt (Kisunla), a monoclonal antibody for Alzheimer's Disease treatment. This policy requires precertification for all commercial plans, mandates specific diagnostic testing (PET/CSF biomarkers, MRI, ApoE4 genotyping), restricts prescribers to geriatricians/neurologists/psychiatrists, and requires ongoing patient registry participation. The policy includes detailed exclusion criteria and ARIA monitoring requirements during continuation therapy.
Medium impact
Pedobarography (CPB 0294, reviewed 2026-04-17)
Aetna·Effective Apr 17, 2026
Aetna has classified pedobarography (foot pressure studies) as experimental, investigational, or unproven and will not cover CPT 96001 (comprehensive computer-based motion analysis with dynamic plantar pressure measurements). This policy applies to all listed ICD-10 diagnoses including diabetic neuropathy, varicose veins, pressure ulcers, and osteoarthritis. Billing teams must deny or refuse to bill pedobarography claims under Aetna plans effective immediately.
Medium impact
Pegaspargase (Oncaspar) (CPB 0959, reviewed 2025-12-03)
Aetna·Effective Dec 3, 2025
Aetna has updated its Pegaspargase (Oncaspar) coverage policy (CPB 0959, effective 2025-12-03) establishing medical necessity criteria for acute lymphoblastic leukemia (ALL), lymphoblastic lymphoma (LL), extranodal NK/T-cell lymphoma (ENKL), and aggressive NK-cell leukemia (ANKL) when used with multi-agent chemotherapy. The policy specifies dosing requirements by age and identifies certain regimens (combined anti-PD-1 antibody, anlotinib, and pegaspargase with radiotherapy) as experimental/investigational.
Medium impact
Pediatric Intensive Feeding Programs (CPB 0809, reviewed 2025-12-11)
Aetna·Effective Dec 11, 2025
Aetna has issued a new clinical policy (CPB 0809, reviewed 2025-12-11) establishing medical necessity criteria for pediatric intensive feeding programs delivered by interdisciplinary teams. Coverage requires documented diagnosis-specific treatment plans, failure of single-discipline treatment over 2 months, and specific malnutrition or feeding problem criteria. Electrical stimulation for swallowing/feeding disorders remains experimental and non-covered.
High impact
Dostarlimab-gxly (Jemperli) (CPB 0993, reviewed 2026-01-27)
Aetna·Effective Jan 27, 2026
Aetna has updated its coverage policy for Dostarlimab-gxly (Jemperli), an immunotherapy drug, effective immediately (reviewed 2026-01-27). The policy establishes specific medical necessity criteria for coverage across multiple cancer types including endometrial, colorectal, ovarian, pancreatic, and non-small cell lung cancers, with mandatory precertification required before treatment initiation. Billing teams must implement prior authorization workflows and ensure claims include documentation of MSI-H/dMMR status or other required biomarkers.
Medium impact
Dry Eyes (CPB 0457, reviewed 2026-07-29)
Aetna·Effective Jul 29, 2026
Aetna has updated its dry eye policy (CPB 0457) effective July 29, 2026, clarifying medical necessity criteria for covered treatments including autologous serum tears, punctal plugs, and tear osmolarity testing. The policy also designates multiple experimental procedures as non-covered, including LipiFlow, acupuncture, amniotic membrane grafting, and numerous biomarker tests. Billing teams must update denial protocols and prior authorization requirements accordingly.
High impact
Durvalumab (Imfinzi) (CPB 0917, reviewed 2026-06-25)
Aetna·Effective Jun 25, 2026
Aetna has updated its coverage policy for durvalumab (Imfinzi) effective June 25, 2026, establishing specific clinical criteria for approval across 12 cancer indications including NSCLC, SCLC, biliary tract, cervical, colorectal, and other solid tumors. The policy requires precertification for all durvalumab treatment and establishes continuation/reauthorization criteria with defined treatment duration limits. Billing teams must implement prior authorization workflows and ensure claims include genetic/molecular testing documentation as specified in the criteria.
High impact
Eculizumab (CPB 0807, reviewed 2026-08-11)
Aetna·Effective Aug 11, 2026
Aetna updated its eculizumab (Soliris, Bkemv, Epysqli) policy for commercial plans, establishing coverage criteria for four indications: atypical hemolytic uremic syndrome (aHUS), paroxysmal nocturnal hemoglobinuria (PNH), generalized myasthenia gravis (gMG), and neuromyelitis optica spectrum disorder (NMOSD). The policy requires precertification for all eculizumab products, mandates neurologist prescription/consultation for gMG and NMOSD, prohibits concomitant use with other complement inhibitors (with limited exceptions), and establishes specific diagnostic and clinical criteria for initial approval and continuation of therapy.
High impact
Edaravone Injection (CPB 0918, reviewed 2026-07-02)
Aetna·Effective Jul 2, 2026
Aetna has updated its Clinical Policy Bulletin for edaravone injection (Radicava and generics) effective 2026-07-02, requiring precertification for all commercial medical plans before administration. The policy covers edaravone only for definite/probable ALS patients with specific functional criteria (ALSFRS-R score ≥2 on all 12 areas) and without continuous invasive ventilation. All other indications remain experimental/investigational.
Medium impact
Pectus Excavatum and Poland's Syndrome: Surgical Correction (CPB 0272, reviewed 2026-04-17)
Aetna·Effective Apr 17, 2026
Aetna updated its coverage policy (CPB 0272) for surgical correction of pectus excavatum and Poland's syndrome, effective April 17, 2026. The policy establishes specific medical necessity criteria including pectus index >3.25, documented functional deficits (cardiac compression or reduced lung capacity ≤80% TLC), and required diagnostic testing. Experimental procedures (Dynamic Compression System, magnetic mini-mover, vacuum bell) and cosmetic repairs are not covered. Billing teams must verify all criteria are met before processing claims for covered CPT codes 21740, 21742, 21743, and Poland's syndrome reconstruction codes.
High impact
Efgartigimod Alfa-fcab (Vyvgart) and Efgartigimod Alfa and Hyaluronidase-qvfc (Vyvgart Hytrulo) (CPB 1002, reviewed 2026-08-11)
Aetna·Effective Aug 11, 2026
Aetna has updated its clinical policy (CPB 1002, effective 2026-08-11) establishing coverage criteria for efgartigimod alfa-fcab (Vyvgart) and efgartigimod alfa and hyaluronidase-qvfc (Vyvgart Hytrulo) for generalized myasthenia gravis (gMG) and chronic inflammatory demyelinating polyneuropathy (CIDP). All claims require precertification before administration, and prescribing must be by or in consultation with a neurologist.
Medium impact
Peanut Immunotherapy (CPB 0968, reviewed 2026-05-27)
Aetna·Effective May 27, 2026
Aetna has issued a new clinical policy (CPB 0968, effective 2026-05-27) establishing coverage criteria for Palforzia (peanut allergen immunotherapy) in commercial plans for patients ages 1-17 with confirmed peanut allergy. Coverage requires allergist/immunologist prescription, confirmed diagnosis via serum IgE or skin prick test, concurrent peanut-avoidant diet, and absence of uncontrolled asthma or eosinophilic gastrointestinal disease. Initial dose escalation and first doses of up-dosing levels must occur in supervised healthcare settings.
Medium impact
Peak Flow Meters (CPB 0059, reviewed 2026-03-18)
Aetna·Effective Mar 18, 2026
Aetna's updated policy (effective 2026-03-18) clarifies that only standard mechanical peak flow meters and spacers are covered as DME for patients with asthma, bronchitis, emphysema, and obstructive pulmonary conditions. Electronic peak flow meters (PeakLog, AirWatch, etc.) are now classified as experimental/unproven and are not covered. Billing teams must ensure claims for electronic devices are denied and only mechanical meters are billed.
Medium impact
Parkinson's Disease (CPB 0307, reviewed 2026-02-24)
Aetna·Effective Feb 24, 2026
Aetna has updated its Parkinson's Disease medical policy (CPB 0307) effective 2026-02-24, clarifying coverage criteria for diagnostic tests, non-surgical treatments (Duopa and infusion pumps), and surgical interventions (pallidotomy). The policy specifies strict medical necessity requirements, prescriber qualifications (neurologist or PD specialist required), and excludes numerous experimental/investigational treatments. Billing teams must ensure prior authorization processes align with the detailed criteria for Duopa therapy, DME equipment, and surgical procedures.
High impact
Parenteral Immunoglobulins (CPB 0206, reviewed 2026-06-18)
Aetna·Effective Jun 18, 2026
Aetna updated its Parenteral Immunoglobulins policy (CPB 0206) effective June 18, 2026, establishing comprehensive precertification requirements and medical necessity criteria for IVIG and SCIG products across 28 specific brand names. All participating providers must obtain prior authorization before administering these immunoglobulins for commercial plans, with detailed clinical criteria for primary immunodeficiency, myasthenia gravis, CIDP, dermatomyositis/polymyositis, and ITP.
High impact
Daratumumab (Darzalex) and Daratumumab and Hyaluronidase-fihj (Darzalex Faspro) (CPB 0904, reviewed 2026-06-08)
Aetna·Effective Jun 8, 2026
Aetna updated its clinical policy for daratumumab (Darzalex) and daratumumab with hyaluronidase (Darzalex Faspro) effective June 8, 2026. The policy establishes medical necessity criteria for multiple indications including multiple myeloma, systemic light chain amyloidosis, HIV-related lymphomas, POEMS syndrome, MIDD, MGRS, and T-ALL. All uses require precertification through Aetna's specialty pharmacy at (866) 752-7021.
High impact
Paralytic Lagophthalmos Treatments (CPB 0366, reviewed 2026-05-22)
Aetna·Effective May 22, 2026
Aetna has updated Clinical Policy Bulletin 0366 (reviewed 2026-05-22) establishing clear medical necessity criteria for paralytic lagophthalmos treatments. Gold-weight/platinum-weight eyelid implants and palpebral springs are now covered only when specific selection criteria are met (delayed facial nerve recovery, exposed cornea, failed conservative treatment). Multiple procedures including muscle transposition, neuroplastic surgery, and autologous spacing grafts are covered for chronic severe cases with no spontaneous recovery likelihood. Botulinum toxin, cerclage sling, hyaluronic acid, and lipofilling remain experimental/unproven. Billing teams must immediately implement prior authorization requirements and ensure correct coding per the expanded covered procedure list.
High impact
Panitumumab (Vectibix) (CPB 0748, reviewed 2025-12-23)
Aetna·Effective Dec 23, 2025
Aetna has updated its panitumumab (Vectibix) clinical policy (CPB 0748) effective 2025-12-23, establishing new coverage criteria for colorectal cancer treatment. The policy now requires RAS mutation testing (wild-type status), mandates precertification for all requests, and specifies strict combination therapy requirements including left-sided tumor limitation for first-line colon cancer and mandatory encorafenib combination for BRAF V600E mutations. All other indications remain experimental/investigational.
High impact
Daunorubicin-Cytarabine Liposome (Vyxeos) (CPB 0921, reviewed 2026-06-12)
Aetna·Effective Jun 12, 2026
Aetna has updated its clinical policy for Vyxeos (daunorubicin-cytarabine liposome) effective immediately, establishing specific medical necessity criteria for initial approval, continuation of therapy, and dosage/administration guidelines for AML, MDS, and CMML treatment. Billing teams must now enforce prior authorization requirements based on diagnosis type, therapy phase (induction/consolidation/re-induction), and cycle limits to ensure claim approval.

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Archive by year

2023 2024 2025 2026

Percutaneous Mitral Valve and Tricuspid Valve Repair (CPB 0880, reviewed 2026-06-05)

Penpulimab-kcqx (CPB 1080, reviewed 2026-04-15)

Pembrolizumab Products (Keytruda and Keytruda Qlex) (CPB 0890, reviewed 2026-07-14)

Pelvic Congestion Syndrome Treatments (CPB 0441, reviewed 2026-07-09)

Diphtheria, Tetanus, and Pertussis Vaccines (CPB 0653, reviewed 2025-12-08)

Pegvaliase-pqpz (Palynziq) (CPB 0933, reviewed 2026-06-09)

Donanemab-azbt (Kisunla) (CPB 1066, reviewed 2025-10-17)

Pedobarography (CPB 0294, reviewed 2026-04-17)

Pegaspargase (Oncaspar) (CPB 0959, reviewed 2025-12-03)

Pediatric Intensive Feeding Programs (CPB 0809, reviewed 2025-12-11)

Dostarlimab-gxly (Jemperli) (CPB 0993, reviewed 2026-01-27)

Dry Eyes (CPB 0457, reviewed 2026-07-29)

Durvalumab (Imfinzi) (CPB 0917, reviewed 2026-06-25)

Eculizumab (CPB 0807, reviewed 2026-08-11)

Edaravone Injection (CPB 0918, reviewed 2026-07-02)

Pectus Excavatum and Poland's Syndrome: Surgical Correction (CPB 0272, reviewed 2026-04-17)

Efgartigimod Alfa-fcab (Vyvgart) and Efgartigimod Alfa and Hyaluronidase-qvfc (Vyvgart Hytrulo) (CPB 1002, reviewed 2026-08-11)

Peanut Immunotherapy (CPB 0968, reviewed 2026-05-27)

Peak Flow Meters (CPB 0059, reviewed 2026-03-18)

Parkinson's Disease (CPB 0307, reviewed 2026-02-24)

Parenteral Immunoglobulins (CPB 0206, reviewed 2026-06-18)

Daratumumab (Darzalex) and Daratumumab and Hyaluronidase-fihj (Darzalex Faspro) (CPB 0904, reviewed 2026-06-08)

Paralytic Lagophthalmos Treatments (CPB 0366, reviewed 2026-05-22)

Panitumumab (Vectibix) (CPB 0748, reviewed 2025-12-23)

Daunorubicin-Cytarabine Liposome (Vyxeos) (CPB 0921, reviewed 2026-06-12)