CommercialPrior AuthMedium impact
Lunsotogene Parvec-cwha (Otarmeni) (CPB 1103, reviewed 12-2026-08)
Aetna·Audiology, ENT (Ear, Nose & Throat), Pediatrics·Medical Policy
Effective date
Dec 8, 2026
We identified it
Aug 27, 2026
Summary
Aetna has issued a new Clinical Policy Bulletin (CPB 1103) establishing coverage criteria for Otarmeni (lunsotogene parvec-cwha), a gene therapy for OTOF-related hearing loss in patients ≤17 years old. The policy requires precertification, mandates administration at Aetna Institutes GCIT Network facilities, and specifies strict eligibility criteria including biallelic OTOF variants, profound sensorineural hearing loss ≥90 dB HL, preserved outer hair cell function, and no prior cochlear implants. Billing teams must implement precertification requirements and ensure claims route through designated networks.
Action Required
By December 8, 2026: (1) Billing team must implement mandatory precertification process for Otarmeni claims by contacting Aetna at (866) 752-7021 or faxing (888) 267-3277 before service delivery. (2) Update billing system to flag all Otarmeni (lunsotogene parvec-cwha) claims with ICD-10 codes H91.8X1-H91.8X9 to require prior authorization before processing. (3) Providers must verify patient age ≤17 years, confirm genetic testing documentation (biallelic OTOF variants), obtain auditory measurements (ABR, otoacoustic emissions or cochlear microphonics), and confirm surgical imaging (CT/MRI) in patient record before submitting claims. (4) Ensure Otarmeni administration occurs ONLY at Aetna Institutes GCIT Designated Network facilities; claims from non-network facilities will be denied. (5) Verify prescriber credentials confirm experience in intracochlear surgery and Otarmeni training. (6) Coding staff must ensure intraoperative neurophysiological monitoring (CPT 95940, 95941, or G0453) is billed with Otarmeni procedure claims. Failure to obtain precertification or utilize network facilities will result in claim denial.