All Insurance Policy Changes (Page 7)

Continuing from page 6. 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
Cosmetic Surgery and Procedures (CPB 0031, reviewed 2026-06-25)
Aetna·Effective Jun 25, 2026
Aetna updated its Clinical Policy Bulletin 0031 on cosmetic surgery coverage (effective 2026-06-25). The policy clarifies which procedures are covered as medically necessary versus excluded as cosmetic, including specific criteria for procedures like blepharoplasty, breast reduction, rhinoplasty, and gender-affirming surgeries. Billing teams must verify medical necessity documentation and apply the detailed inclusion/exclusion criteria to prevent claim denials for cosmetic procedures.
Medium impact
Crizanlizumab-tmca (Adakveo) (CPB 0964, reviewed 2025-12-09)
Aetna·Effective Dec 9, 2025
Aetna has issued a fresh medical policy (CPB 0964, effective 2025-12-09) establishing coverage criteria for crizanlizumab-tmca (Adakveo), a P-selectin monoclonal antibody for reducing vaso-occlusive crises in sickle cell disease patients aged 16+. The policy mandates precertification for all commercial plans, requires hematologist/sickle cell specialist prescription, and establishes specific clinical criteria including prior VOC history and either alternative genotypes or hydroxyurea failure/contraindication/concurrent use.
Medium impact
Daprodustat (Jesduvroq) (CPB 1044, reviewed 2026-01-27)
Aetna·Effective Jan 27, 2026
Aetna has established new coverage criteria for daprodustat (Jesduvroq), an oral medication for anemia in dialysis patients with CKD. The policy requires: (1) patients must have received dialysis for at least 4 months with pretreatment hemoglobin ≤11 g/dL for initial approval, (2) adequate iron stores (TSAT ≥20%) or concurrent iron therapy, and (3) no concurrent use with ESAs. All other indications are considered experimental. This is the first time Aetna has formally established coverage for this newly FDA-approved medication (February 2023).
Medium impact
Crovalimab-akkz (PiaSky) (CPB 1064, reviewed 2026-03-27)
Aetna·Effective Mar 27, 2026
Aetna has established a new medical policy (CPB 1064, effective 2026-03-27) for crovalimab-akkz (PiaSky), a complement C5 inhibitor for treating paroxysmal nocturnal hemoglobinuria (PNH) in patients 13+ years old weighing ≥40 kg. The policy requires precertification, strict diagnostic criteria including GPI-AP deficiency confirmation via flow cytometry, clinical disease manifestations, and prohibits concurrent use with other complement inhibitors. Continuation of therapy requires documentation of positive response and absence of unacceptable toxicity.
Medium impact
Orthopoxvirus Vaccines (CPB 0644, reviewed 2025-12-15)
Aetna·Effective Dec 15, 2025
Aetna updated its orthopoxvirus vaccine policy (CPB 0644) effective 2025-12-15, establishing medical necessity criteria for smallpox and mpox vaccinations. The policy covers pre-exposure vaccination for high-risk groups (laboratory workers, healthcare workers, public health personnel), post-exposure vaccination for exposed individuals, and mpox vaccination for persons with specific risk factors. Billing teams must ensure proper CPT code selection (90611, 90622) and ICD-10 diagnosis codes are used based on the patient's risk category and vaccination indication.
High impact
Orthopedic Casts, Braces and Splints (CPB 0009, reviewed 2026-01-20)
Aetna·Effective Jan 20, 2026
Aetna has updated its comprehensive policy on orthopedic casts, braces, and splints (CPB 0009) effective January 20, 2026. The policy clarifies medical necessity criteria, provider qualifications, and coverage distinctions (DME vs. surgical protocol) for various orthotic devices including back braces, cast-braces, cervical collars, and specialized pediatric braces. Key requirements include prescriber qualifications, provider certification (ABC or BOC), 6-month prescription window, and documented improvement in mobility-related activities of daily living (MRADLs).
High impact
Orthognathic Surgery (CPB 0095, reviewed 2026-03-18)
Aetna·Effective Mar 18, 2026
Aetna has issued a comprehensive clinical policy bulletin (CPB 0095) for orthognathic surgery that defines medical necessity criteria, documentation requirements, and coverage exclusions. The policy requires precertification before orthognathic surgery and clearly delineates covered skeletal deformities (masticatory dysfunction, airway defects, speech impairment with cleft) versus non-covered cosmetic procedures. Billing teams must implement precertification workflows and ensure orthognathic surgery is approved BEFORE any pre-surgical orthodontic treatment begins.
High impact
Organ Prolapse: Selected Procedures (CPB 0858, reviewed 2025-12-24)
Aetna·Effective Dec 24, 2025
Aetna's updated Organ Prolapse policy (CPB 0858, effective 2025-12-24) establishes medical necessity coverage for five specific procedures including laparoscopic suture rectopexy, sacrocolpopexy, and tension-free vaginal tape surgery, while classifying ten additional procedures and technologies as experimental/investigational. Billing teams must update systems to deny claims for non-covered experimental procedures and ensure prior authorization documentation aligns with the five covered interventions.
High impact
Oral Screening and Lesion Identification Systems (CPB 0760, reviewed 2025-12-02)
Aetna·Effective Dec 2, 2025
Aetna has designated oral screening and lesion identification systems as experimental and investigational, effective immediately. Multiple oral cancer detection technologies, biomarker tests, and AI-based screening tools are now non-covered, including ViziLite, chemiluminescence, optical fluorescence imaging, HPV oral testing, and salivary biomarker tests. Billing teams must deny or reject claims for these procedures and update systems to reflect non-coverage status.
High impact
Oral and Esophageal Brush Biopsy (CPB 0686, reviewed 2025-10-15)
Aetna·Effective Oct 15, 2025
Aetna has classified oral and esophageal brush biopsy procedures (including OralCDx, WATS3D/EndoCDx, and related molecular testing) as experimental, investigational, or unproven, effective immediately. Billing teams must deny or reject all claims for these procedures and related codes when submitted for the listed indications.
High impact
Calcitriol, Etelcalcetide, and Paricalcitol Injections (CPB 0022, reviewed 2026-02-11)
Aetna·Effective Feb 11, 2026
Aetna has updated its coverage policy for three injectable medications used in chronic kidney disease management. Etelcalcetide (Parsabiv) now requires documented failure of at least 2 phosphate binders, 2 vitamin D analogs, and a 6-month trial of cinacalcet before approval. Calcitriol and paricalcitol remain covered for hypocalcemia/secondary hyperparathyroidism in hemodialysis patients, and all three drugs require precertification and specialist prescription (endocrinologist or nephrologist).
High impact
Canakinumab (Ilaris) (CPB 0881, reviewed 2026-08-03)
Aetna·Effective Aug 3, 2026
Aetna has updated its Canakinumab (Ilaris) medical policy (CPB 0881) effective 2026-08-03, establishing comprehensive coverage criteria for periodic fever syndromes, Still's disease, systemic juvenile idiopathic arthritis, and gout/pseudogout flares. The policy requires precertification for all uses, mandates TB screening before initiation, prohibits concomitant use with other biologics, and specifies detailed dosing by indication and patient weight. Billing teams must implement prior authorization workflows and ensure providers obtain required testing before claims can be processed.
Medium impact
Optical Coherence Tomography and Microelastography for Solid Tumors and Other Selected Indications (CPB 0886, reviewed 2026-03-03)
Aetna·Effective Mar 3, 2026
Aetna has classified intraoperative optical coherence tomography (OCT) and microelastography for solid tumors and multiple surgical indications as experimental, investigational, or unproven. These procedures are NOT covered, including OCT for tumor margin assessment, lymph node evaluation, breast-conserving surgery guidance, and various ophthalmic and surgical applications. Billing teams must deny or reject all claims for these procedures when billed with the specified CPT codes and cancer-related ICD-10 diagnoses.
Medium impact
Cancer Vaccines (CPB 0557, reviewed 2025-12-02)
Aetna·Effective Dec 2, 2025
Aetna's updated Cancer Vaccines policy (CPB 0557, effective 2025-12-02) classifies multiple cancer vaccine therapies as experimental, investigational, or unproven and denies coverage for these treatments. This includes melanoma vaccines, peptide-based vaccines, DNA vaccines, and stem cell-based vaccines across multiple cancer types. Billing teams must ensure claims for these vaccines are denied and patients are informed of non-coverage before service delivery.
Medium impact
Cantharidin (Ycanth) (CPB 1051, reviewed 2025-12-23)
Aetna·Identified Aug 12, 2026
Aetna has established a new medical policy (CPB 1051) for cantharidin (Ycanth) coverage effective immediately. Ycanth is now covered for topical treatment of molluscum contagiosum in patients 2 years and older when administered by trained healthcare professionals, with a maximum of 4 treatment sessions per infection and no more than 2 applicators per session. Billing teams must implement coverage criteria validation and ensure proper coding with HCPCS code J7354 for claims submission.
High impact
Carfilzomib (Kyprolis) (CPB 0845, reviewed 2026-03-02)
Aetna·Effective Mar 2, 2026
Aetna updated its Clinical Policy Bulletin 0845 for Carfilzomib (Kyprolis) effective March 2, 2026, establishing comprehensive coverage criteria for multiple myeloma, POEMS syndrome, plasma cell-related MIDD, plasma cell-related MGRS, systemic light chain amyloidosis, and Waldenstrom macroglobulinemia. Precertification is required for all Kyprolis use in multiple myeloma patients. The policy defines specific combination therapies, dosing limits, and experimental indications that will affect claims processing and prior authorization workflows.
Medium impact
Caplacizumab-yhdp (Cablivi) (CPB 0949, reviewed 2025-12-03)
Aetna·Effective Dec 3, 2025
Aetna updated its Clinical Policy Bulletin for Caplacizumab-yhdp (Cablivi) effective December 3, 2025, establishing coverage criteria for acquired thrombotic thrombocytopenic purpura (aTTP) treatment. All claims require precertification before submission. Coverage is limited to 30 days post-plasma exchange, with a maximum 28-day extension only if persistent aTTP is documented, and therapy must be discontinued if more than 2 recurrences occur.
High impact
Certolizumab Pegol (Cimzia) (CPB 0761, reviewed 2026-07-01)
Aetna·Effective Jul 1, 2026
Aetna has updated its Certolizumab Pegol (Cimzia) coverage policy to restrict approval to members with contraindication, intolerance, or inadequate response to specific lower-cost targeted immune modulators. The policy now requires documented trials of multiple alternative biologics before Cimzia approval for Crohn's disease, rheumatoid arthritis, plaque psoriasis, psoriatic arthritis, ankylosing spondylitis, and polyarticular juvenile idiopathic arthritis. Precertification remains mandatory for all prescriptions.
Medium impact
Chelation Therapy (CPB 0234, reviewed 2026-02-11)
Aetna·Effective Feb 11, 2026
Aetna updated its Chelation Therapy policy (CPB 0234) effective 2026-02-11, establishing strict medical necessity criteria for deferoxamine mesylate requiring specialist (hematologist or nephrologist) prescription and specific lab values or clinical conditions. The policy limits coverage to three primary indications: transfusional iron overload (ferritin >1000 mcg/L), aluminum toxicity in dialysis patients, and hereditary hemochromatosis when phlebotomy is not feasible. All other chelation therapy uses are classified as experimental/investigational, including off-label applications for cardiovascular disease, neurodegeneration, autism, and dental amalgam mercury toxicity.
High impact
Ciltacabtagene Autoleucel (Carvykti) (CPB 1007, reviewed 2026-03-13)
Aetna·Effective Mar 13, 2026
Aetna has updated its coverage policy for Carvykti (ciltacabtagene autoleucel), a CAR-T cell therapy for relapsed or refractory multiple myeloma. The policy requires precertification for all commercial plans and establishes specific clinical criteria for approval, including prior treatment requirements, lenalidomide refractoriness, and performance status eligibility. Billing teams must implement mandatory prior authorization workflows and ensure claims are submitted with proper documentation of eligibility criteria.
Medium impact
Optic Nerve and Retinal Imaging Methods (CPB 0344, reviewed 2026-05-26)
Aetna·Effective May 26, 2026
Aetna updated CPB 0344 (Optic Nerve and Retinal Imaging Methods, effective 2026-05-26) to clarify coverage criteria for optic nerve and retinal imaging. Key changes include: (1) OCTA is now a medically necessary alternative to fluorescein angiography (FA) for specific AMD, CNV, vasculitis, diabetic retinopathy, and tumor indications; (2) performing both OCTA and FA for the same indication is not medically necessary; (3) OCTA for glaucoma diagnosis/monitoring remains experimental/investigational; (4) remote patient-initiated OCT capture (CPT 0604T, 0605T, 0606T) remains investigational; and (5) optic nerve imaging for glaucoma more than once per year is not medically necessary.
High impact
Onasemnogene Abeparvovec (Zolgensma and Itvisma) (CPB 0953, reviewed 2026-08-10)
Aetna·Identified Aug 12, 2026
Aetna has updated its coverage policy for Onasemnogene Abeparvovec (Zolgensma and Itvisma), gene therapies for spinal muscular atrophy. The policy establishes strict eligibility criteria including age limits, SMN2 gene copy requirements, AAV9 antibody titers, and mandatory precertification. Both medications must be administered at Aetna Institutes GCIT Network facilities, requiring significant workflow changes for billing and prior authorization processes.
High impact
Omalizumab (CPB 0670, reviewed 2026-06-05)
Aetna·Effective Jun 5, 2026
Aetna updated its Clinical Policy Bulletin (CPB 0670) for omalizumab (Xolair and Omlyclo biosimilar) effective June 5, 2026, establishing comprehensive medical necessity criteria across five indications: moderate-to-severe asthma, chronic rhinosinusitis with nasal polyps, chronic spontaneous urticaria, IgE-mediated food allergy, immune checkpoint inhibitor-related toxicity, and systemic mastocytosis. The policy mandates precertification for all omalizumab products through specialty pharmacy channels and requires specific prescriber specialties based on indication.
High impact
Occupational Therapy (CPB 0250, reviewed 2026-05-19)
Aetna·Effective May 19, 2026
Aetna updated its Occupational Therapy medical policy (CPB 0250) effective 2026-05-19, reinforcing strict medical necessity criteria requiring documented improvement within 1 month, written plans of care, licensed provider supervision, and explicit discontinuation when maximal benefit is achieved or progress plateaus. Billing teams must ensure all OT claims include detailed documentation of medical necessity and measurable progress to avoid denials.
Medium impact
Blinatumomab (Blincyto) (CPB 0891, reviewed 2025-10-30)
Aetna·Effective Oct 30, 2025
Aetna has updated its Clinical Policy Bulletin 0891 for blinatumomab (Blincyto), a bispecific CD19-directed CD3 T-cell engager used to treat CD19-positive B-cell precursor acute lymphoblastic leukemia (ALL). The policy clarifies medical necessity criteria for commercial plans, specifying coverage for induction therapy with tyrosine kinase inhibitors, consolidation/maintenance therapy, and relapsed/refractory disease, while designating all other indications as experimental/investigational. This is a fresh policy update (1 day old) requiring immediate implementation.

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Archive by year

2023 2024 2025 2026

Cosmetic Surgery and Procedures (CPB 0031, reviewed 2026-06-25)

Crizanlizumab-tmca (Adakveo) (CPB 0964, reviewed 2025-12-09)

Daprodustat (Jesduvroq) (CPB 1044, reviewed 2026-01-27)

Crovalimab-akkz (PiaSky) (CPB 1064, reviewed 2026-03-27)

Orthopoxvirus Vaccines (CPB 0644, reviewed 2025-12-15)

Orthopedic Casts, Braces and Splints (CPB 0009, reviewed 2026-01-20)

Orthognathic Surgery (CPB 0095, reviewed 2026-03-18)

Organ Prolapse: Selected Procedures (CPB 0858, reviewed 2025-12-24)

Oral Screening and Lesion Identification Systems (CPB 0760, reviewed 2025-12-02)

Oral and Esophageal Brush Biopsy (CPB 0686, reviewed 2025-10-15)

Calcitriol, Etelcalcetide, and Paricalcitol Injections (CPB 0022, reviewed 2026-02-11)

Canakinumab (Ilaris) (CPB 0881, reviewed 2026-08-03)

Optical Coherence Tomography and Microelastography for Solid Tumors and Other Selected Indications (CPB 0886, reviewed 2026-03-03)

Cancer Vaccines (CPB 0557, reviewed 2025-12-02)

Cantharidin (Ycanth) (CPB 1051, reviewed 2025-12-23)

Carfilzomib (Kyprolis) (CPB 0845, reviewed 2026-03-02)

Caplacizumab-yhdp (Cablivi) (CPB 0949, reviewed 2025-12-03)

Certolizumab Pegol (Cimzia) (CPB 0761, reviewed 2026-07-01)

Chelation Therapy (CPB 0234, reviewed 2026-02-11)

Ciltacabtagene Autoleucel (Carvykti) (CPB 1007, reviewed 2026-03-13)

Optic Nerve and Retinal Imaging Methods (CPB 0344, reviewed 2026-05-26)

Onasemnogene Abeparvovec (Zolgensma and Itvisma) (CPB 0953, reviewed 2026-08-10)

Omalizumab (CPB 0670, reviewed 2026-06-05)

Occupational Therapy (CPB 0250, reviewed 2026-05-19)

Blinatumomab (Blincyto) (CPB 0891, reviewed 2025-10-30)