Latest Aetna Update- April 2025
Source – Aetna
No Longer Requiring Precertification (Effective March 1, 2025)
BRCA Genetic Testing (CPT® Code 81433)
Evrysdi® (risdiplam) – J8499
Require Precertification
Effective March 14, 2025
- Ziihera® (zanidatamab-hrii, J3490, J3590, C9399, J9999)
- Bizengri® (zenocutuzumab-zbco, J3490, J3590, C9399, J9999)
- Unloxcyt™ (cosibelimab-ipdl, J3490, J3590, C9399, J9999)
Effective April 1, 2025
- Opdivo Qvantig™ (nivolumab and hyaluronidase-nvhy) – J3490, J3590, C9399, J9999
Medicare only:
Axtle™ (pemetrexed, avyxa) – J9292
Pemrydi RTU® (pemetrexed) – J9324
Effective April 4, 2025
Jubbonti® (denosumab-bbdz) – J3490, J3590, C9399
Wyost® (denosumab-bbdz) – J3490, J3590, C9399
Effective April 18, 2025
- Datroway® (datopotamab deruxtecan-dlnk, J3490, J3590, C9399, J9999) — precertification includes site of care
- Ryoncil® (remestemcel-L, J3490, J3590, C9399, J9999)
Submitting Precertification Requests
Submit requests at least 2 weeks in advance, including the actual date of service.
Use Availity® portal or your EMR system (if enabled) for fast, secure submissions.
Specialty drug precertification (commercial or Medicare) should go through Novologix®, also available on Availity.
Use the “Search by CPT® code” tool on Aetna’s Precertification Lists page to find out if the code requires precertification
State-Specific Notes
Maine & Vermont: Routine changes take effect on the next statutory date (Jan 1, Apr 1, Jul 1, Oct 1).
Texas: Changes apply to fully insured plans only if they meet applicable state regulations.
Effective for Commercial Plans Only
To better align with Centers for Medicare & Medicaid Services (CMS) guidelines, Aetna will now reimburse psychiatric diagnostic evaluation codes 90791 and 90792 only once every six months per member.
Note for Washington State Providers:
For commercial plans, your effective date for changes described in this article will be communicated to you following regulatory review.
FIT/FOBT Coding Policy Update – Effective July 1, 2025
Applies to Commercial and Medicare Members
Starting July 1, 2025, Fecal Immunochemical Test (FIT) and Fecal Occult Blood Test (FOBT) codes 82270, 82274 and G0328 will deny when billed with a date of service within one year after a colonoscopy, flexible sigmoidoscopy or CoIoguard® test (codes 45378-45398, 81528, G0105 and G0121).
Note for Washington State Providers:
For commercial plans, your effective date for changes described in this article will be communicated to you following regulatory review.
Claim and Code Review Program (CCRP) – Starting July 1, 2025
Applies to Commercial, Medicare, and Student Health Members
Effective July 1, 2025, Aetna will introduce new claim edits under the Claim and Code Review Program (CCRP). These updates are designed to improve claims accuracy across commercial, Medicare and Student Health members. You can view these edits on provider portal on Availity.*
Additionally:
Commercial and Medicare providers can use Aetna’s code edit lookup tools (available under the Applications tab) to verify if specific claim edits apply.
Providers may be asked to submit medical records for high-cost, implant, anesthesia, or bundled service claims to validate coding accuracy.
State-specific notes:
Note to Washington State providers: For commercial plans, your effective date for changes described in this article will be communicated to you following regulatory review.
Note to Texas providers: Changes described in this article will be implemented for fully insured plans written in the state of Texas only if such changes are in accordance with applicable regulatory requirements. Changes for all other plans will be as outlined in this article.
Note to Maine and Vermont providers: For commercial plans, your effective date for routine changes described in this article will be the statutory date of January 1, April 1, July 1 or October 1, whichever date follows the effective date(s) referred to in this article. Changes required by state or federal law, or pursuant to revisions of Current Procedural Terminology (CPT®) codes published by the American Medical Association, may be effective outside the statutory dates outlined above.