CPT 86160 is referenced in 5 tracked payer policy changes from Capital Blue Cross and Aetna. For billers and coders, staying current on payer-specific coverage criteria, reimbursement rules, and prior-authorization requirements for CPT 86160 is critical to clean claim submission. Each entry below links to the full policy analysis with effective dates and action steps.
Capital Blue Cross updated its medical policies, with most changes effective July 1, 2026 unless otherwise indicated. Prior authorization for Loargys and Exdensur now applies to J3590 and C9399 starting July 1, 2026, and the PA requirement for Exdensur moved from a 6/1 date to 7/1. Many revised medical injectable policies take effect August 1, 2026, and several policies remove procedure codes that will now be managed by EviCore.
Aetna Clinical Policy Bulletin 0782 sets the criteria for hereditary angioedema (HAE) drugs under commercial medical plans, and precertification is required for these agents in applicable plan designs. Cinryze, Dawnzera, Haegarda and Takhzyro are considered medically necessary for prevention of HAE attacks when they are prescribed by or in consultation with a prescriber who specializes in the management of HAE, are not used in combination with another prophylaxis medication, and the member meets the initial criteria, including C1 inhibitor deficiency confirmed by laboratory testing or a normal C1 inhibitor with a qualifying pathogenic variant or a family history of angioedema refractory to high-dose antihistamine therapy for at least one month. Berinert is considered medically necessary for treatment of acute attacks only when the member has a contraindication, intolerance or ineffective response to the equivalent alternative Ruconest, tried for one month, and all other indications of these agents are considered experimental, investigational or unproven.
Aetna considers obinutuzumab (Gazyva) medically necessary for commercial medical plans for these indications: chronic lymphocytic leukemia or small lymphocytic lymphoma, as a single agent or in combination with acalabrutinib, venetoclax, bendamustine, or chlorambucil, or with high-dose methylprednisolone for del(17p)/TP53 mutation disease; follicular lymphoma for up to 30 months total; extranodal, splenic and nodal marginal zone lymphoma; histologic transformation of indolent lymphomas and several high-grade B-cell lymphomas, Burkitt lymphoma, HIV-related B-cell lymphomas, post-transplant lymphoproliferative disorders and Castleman disease; mantle cell lymphoma with TP53 mutation; hairy cell leukemia in combination with vemurafenib for members who cannot tolerate purine analogs; and active lupus nephritis in members 18 years of age or older. For several lymphoma indications, use as a substitute for rituximab is covered when the member has intolerance or rare complications from rituximab, such as mucocutaneous reactions. Continuation of therapy is covered when there is no evidence of unacceptable toxicity or disease progression, and for lupus nephritis when the member achieves or maintains a positive clinical response. Re-challenge with the same anti-CD20 monoclonal antibody is not recommended. Aetna considers all other indications experimental, investigational or unproven, including acute lymphoblastic leukemia, B-cell prolymphocytic leukemia, anti-MAG demyelinating neuropathy, immune thrombotic thrombocytopenic purpura, lymphoma of the cervix, nephrotic syndrome, rheumatoid arthritis, systemic lupus erythematosus, Waldenstrom macroglobulinemia, and the combination with pixantrone for relapsed aggressive lymphoma. The available dose is a 1,000 mg/40 mL single-dose vial for intravenous infusion only, and the policy states that it is not to be given as an intravenous push or bolus.
Aetna considers outpatient IV antibiotic therapy medically necessary for Lyme disease only when the clinical presentation is compatible with the disease and supported by two-tier serologic testing. Once Lyme disease is definitively diagnosed, an initial 4-week course of outpatient IV antibiotic therapy is medically necessary for persistent Lyme arthritis after failing a 4-week course of oral antibiotics, for moderate-to-severe cardiac or neurologic involvement, and for specified cases in pregnant women, and one repeat 4-week course is medically necessary with objective evidence of relapse, progression of organ damage, or a new focus or type of organ damage. Aetna considers IV antibiotic therapy for early Lyme disease, additional antibiotic therapy for post-treatment persistently fatigued patients, and a range of listed tests and treatments experimental, investigational, or unproven.
Aetna Clinical Policy Bulletin 0782 covers hereditary angioedema (HAE) agents for commercial medical plans. Precertification of HAE agents is required of all Aetna participating providers and members in applicable plan designs. Aetna considers prophylactic HAE agents medically necessary when the drug is prescribed by or in consultation with a prescriber who specializes in HAE management, is not used in combination with other HAE prophylaxis, and the member meets the C1 inhibitor criteria at diagnosis with other causes of angioedema ruled out. Berinert is considered medically necessary for acute attacks only for members with a contraindication, intolerance or ineffective response to Ruconest after a one-month trial. Continuation of prophylaxis requires a significant reduction in attack frequency (for example, at least 50 percent) and reduced use of medications for acute attacks.
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