By 2026-06-25: Billing and authorization teams must implement the following changes: (1) Update pre-authorization workflows to require physicians to submit medical necessity documentation (photographs, clinical letters, chart records) for all procedures listed in CPB 0031 Section 'Medical Necessity Surgeries and Procedures' before claim submission. (2) Configure billing system to automatically flag and deny claims for procedures listed under the 'Cosmetic' section (e.g., labiaplasty, cheek implants, buttock lift, breast augmentation for non-gender-dysphoria cases) unless prior authorization explicitly overrides with medical necessity justification. (3) Create a reference guide for front-desk and authorization staff listing 35+ procedures with their medical necessity criteria and required documentation. (4) For procedures with conditional coverage (e.g., earlobe repair only for traumatic injury, not pierced-hole closure), train billing staff to verify procedure indication in clinical notes before processing. (5) Update claim denial templates to cite the specific cosmetic exclusion from CPB 0031. Providers must submit appeals with medical necessity documentation if they dispute cosmetic classification. Failure to implement will result in improper claim payments for non-covered cosmetic procedures and potential recovery audits from Aetna.

By January 20, 2026: Billing team must implement the following changes: (1) Verify all orthotic device claims include prescriber credentials (physician, NP, podiatrist, or qualified health professional per state law) before processing; (2) Confirm provider certification status with American Board for Certification (ABC), Board of Certification/Accreditation (BOC), or state licensure documentation on file prior to claim submission; (3) Update claim scrubbing rules to reject cast-braces and back braces without evidence of prescription within 6 months of device provision; (4) Flag post-operative back braces (must be applied within 6 weeks post-surgery) separately from DME back braces in billing system; (5) Implement requirement that custom-fitted back braces must show prior failure/contraindication/intolerance to off-the-shelf braces or post-operative use, or claims will be denied; (6) Educate providers that cervical foam neck collars are non-covered (not durable) and should not be billed; (7) For pediatric hip braces and scoliosis braces, ensure documentation demonstrates stabilization/correction of congenital defect or medical necessity. Claims lacking proper documentation of prescriber qualifications, provider certification, or medical necessity criteria will face denial or recoupment.

REQUIREMENTS: - Immediately (upon implementation): Billing and precertification teams must establish a mandatory precertification workflow for ALL orthognathic surgery cases (CPT 21083, 21084, 21085, 21088, 21141, 21142, 21143, 21145, 21146). Route all precertification requests to Aetna's Oral and Maxillofacial Surgery Unit. - Before any orthognathic surgery claim is processed: Verify that precertification was obtained BEFORE pre-surgical orthodontic treatment was initiated. Deny claims if precertification approval predates orthodontic care start date. - Update all patient eligibility verification forms and provider scheduling systems to flag orthognathic cases for mandatory precertification before any treatment begins. - Provide providers with documentation checklist (skeletal deformity study models, pre-orthodontic imaging, detailed functional impairment description) to include with precertification requests. - Reject and deny any orthognathic surgery claims performed for cosmetic purposes (including isolated mentoplasty/chin surgeries for genial hypoplasia, hypertrophy, or asymmetry). - Implement billing rules to separate orthodontic treatment costs (pre- and post-surgical) as dental benefits—do NOT process under medical claims. - Flag and deny any claims for experimental/investigational procedures: condylar positioning devices, low-level laser therapy for post-op management, manual lymphatic drainage, non-biodegradable osteosynthesis, 3D virtual treatment planning (CASNOS), or Kinesio taping. - CONSEQUENCE: Failure to obtain precertification before orthodontic care or failure to verify precertification will result in claim denial per policy language.

By 2025-12-24: Billing team must update billing software to flag and deny claims for experimental procedures (biodegradable cog threads, biologic grafts, laser therapy, pectopexy, TENS therapy, vNOTES procedures, vaginal tactile imaging, genetic testing for prolapse). Verify that only CPT codes 57120, 57280, 57282, 57288, 57425 process as covered when paired with ICD-10 codes K62.2, K62.3, N81.0-N81.9. Implement system edits to reject CPT 0487T, 0552T, 57267/57284/57285 with biologic grafts, HCPCS A4556-A4595, C1781, E0720, E0730, G0283, S8948, and genetic testing codes (81400-81479) for organ prolapse indications. Update encounter templates to require documentation of medical necessity for covered procedures. Inform providers that claims for experimental procedures will be denied. Flag ICD-10 codes N39.41-N39.498, N95.2, R10.2-R10.24, R32, R39.81 as non-covered for this policy.