CommercialPrior AuthHigh impact
OfficeLink Updates - October 2024 notices and reminders (PDF)
Aetna·Dermatology, Oncology, Gastroenterology +3 more·Newsletter
Effective date
Jan 1, 2025
We identified it
Jun 19, 2026
Summary
Aetna is implementing multiple changes including new precertification requirements for specialty drugs (effective September-October 2024), pathology billing restrictions with Mohs surgeries, and several claim edits starting January 1, 2025. Most significantly, pathology codes will be denied when billed same-day as Mohs procedures unless for separate lesions.
Action Required
Immediately: Update precertification system to require prior auth for 13 new specialty drugs listed (effective September-October 2024). By January 1, 2025: Billing team must update systems to automatically deny pathology codes 88300-88309 and 88331-88334 when billed same-day as Mohs codes 17311-17315 unless separate lesion documented. Update claim edits for PC/TC indicator '5' restrictions for hospital settings. Behavioral health team must rebundle H2017/H2019/H2030 codes exceeding 16 units. Deny Cologuard within one year of colonoscopy. Use CPT 81418 for pharmacogenomic panels instead of unbundled codes.