Medicare AdvantagePrior AuthHigh impact
OfficeLink Updates - August 2025 notices and reminders (PDF)
Aetna·Dermatology, General Surgery, Plastic Surgery +2 more·Newsletter
Effective date
Aug 1, 2025
We identified it
Jun 19, 2026
Summary
Aetna is implementing three major changes: a new payment structure for Medicare inpatient stays 1+ midnight that pays faster at observation rates with appeal rights, new CPT code requirements for lesion excisions based on tissue depth, and expanded precertification requirements for multiple specialty drugs including biosimilars.
Action Required
By August 1, 2025: Billing team must update precertification system to require prior authorization for Conexxence, Bomyntra, Omlyclo, and other listed specialty drugs with codes J3490, J3590, C9399. By November 1, 2025: Update billing rules to use codes 11400-11471 and 11600-11646 only for cutaneous/superficial subcutaneous lesions, and codes 21011-28045 for deep subfascial/submuscular lesions. By November 15, 2025: Prepare for new Medicare inpatient payment structure - claims for 1+ midnight stays will be paid at observation rates initially with appeal rights for full inpatient rates.