Key Reimbursement and Precertification Updates from Aetna

Key Reimbursement and Precertification Updates from Aetna 

Changes to Hospital-Owned Practice Reimbursement 

Effective Jun. 1, 2025, for commercial members, hospital-owned practices will no longer receive separate reimbursement for facility or practice expenses when these costs are already included in the physician’s payment. 

Providers in Maine and Vermont should note that for commercial plans, the effective date for these changes will be the next statutory date following June 1, which could be January 1, April 1, Jule 1, or October 1. In Washington, the implementation date will be announced after regulatory review. 

Updates to Aetna's National Precertification List (NPL) 

These updates impact both commercial and Medicare members. 

Changes Effective Febr. 1, 2025 

• Precertification No Longer Required: 
• Thawing of cryopreserved embryos (CPT 89352) 
• New Precertification Requirements: 
• Tecentriq Hybreza™ (atezolizumab and hyaluronidase-tqjs) 
• Ocrevus Zunovo™ (ocrelizumab and hyaluronidase) 
• Boruzu (bortezomib) 
• Tremfya® (guselkumab) 
• Precertification for these drugs also includes the site of care requirements. 
• Medicare-Specific Precertification Requirements: 
• Knee arthroscopy procedures (CPT 29875, 29876, 29877, 29879) 
• Lupron Depot® (leuprolide acetate, J1950) 

Changes Effective Febr. 26, 2025 

• New Precertification Requirements (Including Site of Care): 
• Aucatzyl® (obecabtagene autoleucel, obe-cel) 
• Kebilidi (eladocagene exuparvovec-tneq) 

Emergency Services & Precertification 

Emergency services do not require precertification, except in the following cases: 

• If additional procedures requiring precertification are performed on a different day than the emergency room visit. 
• If an emergency visit results in an inpatient hospital admission, providers must report the admission within two business days. 

Submitting Precertification Requests 

Providers should submit precertification requests at least two weeks before the service date. Requests can be submitted online through the Availity provider portal for a streamlined and secure process. 

Additionally, electronic medical record (EMR) systems integrated for electronic precertification requests can be used. Providers can verify whether a CPT® code requires precertification by using the “Search by CPT® code” tool on the NPL page. 

For specialty drug precertification requests for commercial and Medicare members, providers should submit through Novologix, also available via Availity. 

CPAP Adherence Requirements 

Effective Apr. 1, 2025, CPAP (Continuous Positive Airway Pressure) devices and related supplies will no longer be reimbursed unless adherence to positive airway pressure therapy is documented with adherence codes G8851, G8854, and G8855 on the claim. 

Providers in Washington should await further notice on the effective date, as it is subject to regulatory review. 

Source: Aetna 

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