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

By 2026-02-24, the billing and prior authorization teams must: (1) Update prior authorization workflows to enforce Aetna's Duopa approval criteria — requiring documentation that members have tried and failed oral carbidopa-levodopa PLUS one of three specific adjunctive agents (COMT inhibitor, dopamine agonist, or MAO-B inhibitor), have "off" periods of ≥3 hours daily despite optimization, and are levodopa-responsive with defined "on" periods; (2) Configure authorization rules to require neurologist or PD specialist prescriber attestation before processing Duopa, CADD-Legacy 1400 pump, or Vyafuser pump claims; (3) Update denial templates to reference experimental/investigational status for biomarker testing (alpha-synuclein variants, LRRK2, genetic panels), wearable sensors, device therapies (Cala-Trio, Equistasi, SpeechVive), and surgical procedures not explicitly covered (gene therapy, stem cell transplantation, fetal tissue transplantation); (4) Train prior authorization staff on pallidotomy coverage restrictions — denials must be issued for members with Hoehn and Yahr Stage V, severe dementia, atypical parkinsonian syndromes, or who have not exhausted pharmacotherapy; (5) Implement clinical review protocols to verify members meet continuation criteria (demonstrated positive clinical response) before approving ongoing Duopa therapy. Failure to enforce these criteria will result in claim denials and member appeals.