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B20

PAYER POLICY CHANGES

B20 Insurance Policy Changes

ICD-10 B20 is officially defined as "Human immunodeficiency virus [HIV] disease." code B20 is referenced in 50 tracked payer policy changes from Aetna, Independence Blue Cross, and 1 other payer. For billers and coders, staying current on payer-specific coverage criteria, reimbursement rules, and prior-authorization requirements for code B20 is critical to clean claim submission. Each entry below links to the full policy analysis with effective dates and action steps.

Aetna · Identified Aug 13, 2026High impact
Clesrovimab-cfor (Enflonsia) (CPB 1088, reviewed 09-2025-10)
Aetna's commercial policy for Enflonsia (clesrovimab-cfor), CPB 1088, covers one intramuscular dose to prevent RSV lower respiratory disease in infants under 8 months entering their first RSV season, when the source's criteria are met. Those criteria turn on maternal RSV vaccine status and whether the infant has already received clesrovimab, nirsevimab or palivizumab, and commercial plans may require a trial of a lower-cost preferred drug first.
Independence Blue Cross · Effective Nov 2, 2026Medium impact
MA08.108g, Polatuzumab vedotin-piiq (Polivy®)
Independence Blue Cross Medicare Advantage policy MA08.108g expands coverage for Polivy (HCPCS J9309): it adds the GemOx-R regimen for Burkitt lymphoma, refines CAR T-cell sequencing criteria, and adds ICD-10 codes as medically necessary. The policy became effective November 2, 2026, so it is already in effect, and it covers Polivy under the Part B medical benefit only, not the Part D pharmacy benefit.
Independence Blue Cross · Effective Nov 2, 2026Medium impact
MA08.139e, Loncastuximab tesirine-lpyl (Zynlonta®)
Independence Blue Cross Medicare Advantage policy MA08.139e adds Waldenstrom macroglobulinemia and lymphoplasmacytic lymphoma as a medically necessary use of Zynlonta (HCPCS J9359) for patients who have had a covalent BTK inhibitor or cannot take one, and adds a list of ICD-10 codes to that coverage. The policy became effective November 2, 2026, so it is already in effect, and it covers Zynlonta only under the Part B medical benefit, not the Part D pharmacy benefit.
Independence Blue Cross · Effective Nov 2, 2026Medium impact
08.01.59g, Polatuzumab vedotin-piiq (Polivy®)
Independence Blue Cross commercial policy 08.01.59g expands coverage for Polivy (HCPCS J9309): it adds the GemOx-R regimen for Burkitt lymphoma and refines CAR T-cell sequencing criteria, and it adds a long list of ICD-10 codes as medically necessary. The policy became effective November 2, 2026, so it is already in effect, and the notice's excerpt does not include the full criteria for the new mantle cell lymphoma heading.
Independence Blue Cross · Effective Nov 2, 2026Medium impact
08.00.59e, Loncastuximab tesirine-lpyl (Zynlonta®)
Independence Blue Cross added Waldenstrom macroglobulinemia and lymphoplasmacytic lymphoma as a medically necessary use of Zynlonta (HCPCS J9359) for patients who have had a covalent BTK inhibitor or cannot take one, and it added a long list of ICD-10 codes to that coverage. The policy became effective November 2, 2026, so it is already in effect as of the analysis date, and it applies to IBX commercial plans.
Independence Blue Cross · Effective Jun 29, 2026Medium impact
MA08.011i, Erythropoiesis Stimulating Agents (ESAs)
Independence Blue Cross updated MA08.011i to align with FDA labeling and NCCN guidelines for Erythropoiesis Stimulating Agents (ESAs). The policy revises medical necessity criteria for myelodysplastic syndrome, cancer-related anemia, HIV/AIDS, and pediatric chronic kidney disease, and adds 18 new ICD-10 diagnosis codes effective June 29, 2026.
Blue Cross & Blue Shield of Mississippi · Effective Jun 15, 2026Medium impact
Immunoglobulin Therapy
BCBSMS's Immunoglobulin Therapy policy states that prior authorization is required, and the 06/15/2026 update added Yimmugo to the products not covered on any BCBSMS Formulary. The same effective-dated update revised the medically necessary criteria for formulary intravenous and subcutaneous immunoglobulin therapy and changed the investigational list to specify sepsis in adults. Alyglo, Asceniv, Bivigam, Cuvitru, Flebogamma DIF, Gammagard S/D, Gammaplex, GamaSTAN, Hyqvia, Panzyga and Yimmugo are listed as not covered.
Independence Blue Cross · Effective Jun 15, 2026Medium impact
08.00.75r, Erythropoiesis-Stimulating Agents (ESAs)
Independence Blue Cross updated policy 08.00.75r on Erythropoiesis-Stimulating Agents (ESAs) effective June 15, 2026, revising coverage criteria for myelodysplastic syndrome, cancer-related anemia, HIV/AIDS, and pediatric chronic kidney disease based on updated FDA labeling and NCCN guidelines. Multiple ICD-10 diagnosis codes were added to the policy to align with current diagnostic classifications. Billing teams must update systems to recognize these new diagnosis codes when processing ESA claims.
Aetna · Effective Apr 8, 2026Medium impact
Etuvetidigene Autotemcel (Waskyra) (CPB 1097, reviewed 2026-10-05)
Waskyra (etuvetidigene autotemcel) is a one-time autologous gene therapy that Aetna considers medically necessary for classic Wiskott-Aldrich syndrome when the initial approval criteria are met. Those criteria include age 6 months or older, a WAS gene pathogenic variant with absent or truncated WASP expression or a Zhu clinical score of 3 or higher, and no suitable HLA-identical sibling donor. Precertification is required of all Aetna participating providers and members in applicable plan designs. Gene and cellular therapies must be given at an Aetna Institutes GCIT Network unless the member's plan has elected not to require it. Aetna considers all other indications experimental, investigational or unproven.
Aetna · Effective Oct 9, 2025Medium impact
Clesrovimab-cfor (Enflonsia) (CPB 1088, reviewed 2026-10-09)
Aetna considers a single intramuscular injection of clesrovimab-cfor (Enflonsia) medically necessary for preventing RSV lower respiratory tract disease in infants younger than 8 months who are born during or entering their first RSV season, when the selection criteria are met. Under those criteria, an infant qualifies when maternal RSV vaccine was not received or its status is unknown, when the infant was born less than 14 days after maternal vaccination, or when the maternal vaccine was received in a prior pregnancy, and the infant has not previously received clesrovimab-cfor, nirsevimab-alip, or palivizumab. The policy also states that an additional dose may be given as soon as an infant undergoing cardiac surgery with cardiopulmonary bypass during or entering the first RSV season is stable after surgery, and Aetna considers all other indications experimental, investigational, or unproven.
Blue Cross & Blue Shield of Mississippi · Effective Oct 1, 2025Medium impact
Human Growth Hormone and Insulin-like Growth Factor-1
Already effective 2025-10-01: Prior authorization is required for the growth hormone products listed in this policy, and the policy criteria were extensively revised. Use of samples by an individual will not be considered current or stable therapy to satisfy policy requirements. Egrifta SV and Egrifta WR are considered not medically necessary because the reduction of excess abdominal fat is considered cosmetic, and Genotropin, Humatrope, Ngenla, Omnitrope, Skytrofa, Sogroya and Zomacton are considered not medically necessary because other formulary alternatives are covered by the plan.
Independence Blue Cross · Effective May 28, 2025Medium impact
MA05.021b, Injectable Dermal Fillers for Cosmetic Procedures
Independence Blue Cross updated MA05.021b to version MA05.021c, clarifying that injectable dermal fillers for cosmetic procedures remain covered ONLY for HIV-associated facial lipodystrophy syndrome (LDS) when specific medical necessity criteria are met. The policy explicitly excludes all other dermal fillers and cosmetic indications, including hyaluronic acid products, collagen, autologous fat transfer, and others. Four new CPT codes (11950-11952, 11954) were added to the policy's billing code list.
Aetna · Identified Oct 15, 2026Medium impact
Axicabtagene Ciloleucel (Yescarta) (CPB 0924, reviewed 2026-10-09)
This bulletin covers Yescarta (axicabtagene ciloleucel) for commercial medical plans, and Yescarta requires precertification through National Medical Excellence (NME) at 1-877-212-8811. Aetna considers one dose medically necessary for the B-cell lymphoma indications listed in the policy, including the large B-cell lymphoma subtypes listed, follicular lymphoma after two or more lines of systemic therapy, histologic (Richter) transformation to DLBCL, relapsed or refractory pediatric primary mediastinal large B-cell lymphoma, and relapsed or refractory primary central nervous system lymphoma. Aetna considers acute lymphoblastic leukemia, indolent non-Hodgkin lymphomas other than the subtypes listed, mantle cell lymphoma, solid tumors and repeat administration experimental, investigational, or unproven, and members with a previous CD19-directed CAR T-cell therapy or an ECOG performance status of 3 or greater are not eligible.
Aetna · Identified Oct 10, 2026Medium impact
Immune Globulins for Post-Exposure Prophylaxis (CPB 0544, reviewed 2026-10-07)
Aetna considers immune globulins medically necessary for hepatitis B, cytomegalovirus, Rho-D, rabies, varicella zoster, tetanus, vaccinia, botulism, hepatitis A, measles (rubeola) and rubella exposures or conditions, and considers all other indications experimental, investigational, or unproven. Each product has its own initial criteria, such as hepatitis B immune globulin for members who had contact with an individual diagnosed with hepatitis B virus, Rho-D immune globulin for unsensitized Rh-negative women at 24 to 28 weeks gestation unless the father is known to be Rh-negative, and varicella zoster immune globulin for high-risk individuals with significant exposure to varicella. Continuation of therapy for each product is considered medically necessary for all members, including new members, who meet all initial medical necessity criteria.
Aetna · Identified Oct 6, 2026Medium impact
Marnetegragene Autotemcel (Kresladi) (CPB 1102)
Aetna's Clinical Policy Bulletin 1102 addresses marnetegragene autotemcel (Kresladi) for commercial medical plans, and it points to the Medicare Part B criteria for Medicare. Precertification is required of all Aetna participating providers and members in applicable plan designs, through National Medical Excellence at 877-212-8811. Unless the member's health plan has elected not to require it, gene and cellular therapies must be administered at an Aetna Institutes GCIT Network, and Aetna considers the one-time administration medically necessary when all listed LAD-I criteria are met.
Aetna · Identified Oct 6, 2026Medium impact
Pegzilarginase-nbln (Loargys) (CPB 1101)
Aetna's new clinical policy bulletin (CPB 1101, source dated 2026-10-06) sets the criteria for pegzilarginase-nbln (Loargys) on commercial medical plans for arginase 1 deficiency in patients aged 2 to under 32. Precertification is required, the drug must be prescribed by or with a metabolic or enzyme disorder specialist, and Aetna treats all other indications as experimental, investigational or unproven. No effective date is stated in the source, so check current applicability before acting.
Aetna · Identified Oct 5, 2026Medium impact
HIV Testing (CPB 0542, reviewed 2026-08-28)
Aetna considers HIV testing medically necessary for screening persons for HIV infection according to the recommendations of the U.S. Preventive Services Task Force and the CDC, starting with an FDA-approved antigen/antibody combination immunoassay. Reactive specimens go to an FDA-approved HIV-1/HIV-2 antibody differentiation immunoassay and, when indicated, an FDA-approved HIV-1 nucleic acid test. Aetna does not cover home HIV test kits that do not require a physician's prescription under any plans.
Aetna · Identified Oct 1, 2026Medium impact
Diagnosis of Vaginitis (CPB 0643, reviewed 2026-09-25)
Aetna's vaginitis diagnosis policy (CPB 0643), last reviewed 09/25/2026, considers nucleic acid amplification or DNA probe tests for trichomonas, Candida and Gardnerella medically necessary for members with dysuria or symptoms of vaginitis. It also considers BVBlue sialidase testing, PCR tests for bacterial vaginosis and Candida, and pH and amine testing medically necessary for women with symptoms. Trichomonas screening is considered medically necessary for women with listed risk factors, including HIV-positive women, new or multiple partners, history of sexually transmitted diseases, exchange of sex for payment, injection drug use, or high-prevalence settings. Routine screening of asymptomatic women for Candida and Gardnerella, Pap smears for the diagnosis of Candida vulvovaginitis, the uBiome SmartJane screen and the 27-organism vaginal pathogen panel are experimental, investigational or unproven, and screening asymptomatic pregnant women for bacterial vaginosis is experimental and not covered.
Aetna · Identified Sep 29, 2026Medium impact
Clesrovimab-cfor (Enflonsia) (CPB 1088)
Aetna Clinical Policy Bulletin 1088, Clesrovimab-cfor (Enflonsia), addresses this RSV antibody for commercial medical plans. It states Aetna considers the CDC ACIP recommendations for a single intramuscular injection medically necessary to prevent RSV lower respiratory tract disease when the listed infant criteria are met. The source text does not state an effective date or describe what changed.
Aetna · Identified Aug 19, 2026Medium impact
HIV Drug Susceptibility and Resistance Tests (CPB 0316, reviewed 2026-05-21)
Aetna considers HIV drug susceptibility and resistance tests, phenotypic or genotypic, medically necessary during acute new-onset HIV infection, for suboptimal viral load suppression after antiretroviral therapy starts, and for virologic failure during highly active antiretroviral therapy (HAART). Phenotypic and genotypic tests performed at the same time are not medically necessary because the approach is duplicative. HIV tropism testing with phenotypic recombinant virus assays (Trofile) or genotypic HIV V3-loop assays is medically necessary before a CCR5 antagonist such as maraviroc (Selzentry) is started.
Aetna · Identified Aug 19, 2026Medium impact
Varicella and Herpes Zoster Vaccines (CPB 0115, reviewed 2026-03-19)
Aetna Clinical Policy Bulletin 0115 covers varicella vaccine as a preventive service under the CDC ACIP recommendations, and covers the combined MMRV vaccine (ProQuad) as an alternative to separate MMR and varicella vaccines for children 12 months to 12 years where simultaneous administration of MMR and varicella vaccines is indicated. It covers the two-dose recombinant zoster vaccine Shingrix for prevention of herpes zoster in adults aged 50 years and older, in adults aged 50 years and older who previously received Zostavax, and in adults aged 18 years and older who are or will be at increased risk of herpes zoster due to immunodeficiency or immunosuppression. Shingrix is considered experimental, investigational or unproven for treatment of zoster or postherpetic neuralgia, for prevention of primary varicella infection, for repeat booster doses beyond the two-dose series and for all other indications not listed, and Zostavax is no longer available for use in the United States as of November 18, 2020.
Aetna · Identified Aug 18, 2026Medium impact
Obinutuzumab (Gazyva) (CPB 0877, reviewed 2026-06-05)
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 · Identified Aug 18, 2026Medium impact
HIV Testing (CPB 0542, reviewed 2025-11-26)
Aetna considers HIV testing medically necessary for screening according to the recommendations of the U.S. Preventive Services Task Force and the CDC. Initial testing uses an FDA-approved antigen/antibody combination immunoassay, and further testing follows only for reactive results. Aetna does not cover home HIV test kits that do not require a physician's prescription under any plan, including the Confide Home HIV Test and the Home Access HIV Test System.
Aetna · Identified Aug 17, 2026Medium impact
Hepatitis Screening (CPB 0835, reviewed 2025-12-09)
Aetna considers hepatitis B screening medically necessary for listed groups, including people on hemodialysis, blood or organ donors, pregnant women, people with HIV, injection drug users, men who have sex with men, and people born in regions with a 2% or higher HBV prevalence. Hepatitis C screening is medically necessary for listed groups, and one-time HCV testing without prior risk assessment is medically necessary for adults aged 18 years and older. Hepatitis D screening is medically necessary for people with HBsAg-positive hepatitis B infection and significant risk factors, while hepatitis E screening in the peri-transplant period is experimental, investigational, or unproven.
Aetna · Identified Aug 17, 2026Medium impact
Flow Cytometry, Ektacytometry, DNA Ploidy, and S-phase Fraction (CPB 0351, reviewed 2026-05-21)
Aetna considers flow cytometry for cell surface markers medically necessary for listed conditions, including abnormal tissue, bone marrow or blood histology suspicious for lymphoma, leukemia or myelodysplastic syndrome, multiple myeloma, paroxysmal nocturnal hemoglobinuria, primary immunodeficiencies, Sezary syndrome diagnosis, and T-cell monitoring for HIV infection and AIDS. Flow-cytometry-derived DNA ploidy or S-phase fraction is medically necessary only in localized cancers without metastatic disease, namely endometrial adenocarcinoma, gastric cancer, mediastinal neuroblastoma, medulloblastoma, ovarian carcinoma, partial hydatidiform mole, prostatic adenocarcinoma, renal cell adenocarcinoma and urinary bladder carcinoma, and only when the prognostic information will affect treatment decisions. Ektacytometry is medically necessary for red blood cell cytoskeleton and hydration disorders when red blood cell morphology does not provide a clear diagnosis. The red blood cell adhesion index for all indications, DNA ploidy or S-phase testing in breast, cervical, colorectal, non-small cell lung, small cell lung and pediatric intracranial tumors, and microfluidic flow adhesion assays for sickle cell disease are experimental, investigational or unproven.
Aetna · Identified Aug 16, 2026Medium impact
Nebulizers (CPB 0065, reviewed 2026-03-18)
Aetna covers small volume nebulizers and related compressors for listed indications, including antibiotics for cystic fibrosis or bronchiectasis, beta-adrenergics and other inhaled drugs for COPD, dornase alfa for cystic fibrosis or primary ciliary dyskinesia, and epinephrine for croup. Large volume nebulizers are considered medically necessary for pentamidine, bronchiectasis, cystic fibrosis, tracheobronchial stents, and tracheostomy, and ultrasonic nebulizers are considered medically necessary only for tobramycin (Tobi) delivery in members with cystic fibrosis who meet the criteria for a standard nebulizer and the additional criteria in the policy. Aetna considers these nebulizers and related equipment experimental, investigational, or unproven for all other indications, including nebulized corticosteroids for nasal polyps and viral wheezing, nebulized lidocaine, and nebulized magnesium for pediatric asthma.
Aetna · Identified Aug 16, 2026Medium impact
Nirsevimab-alip (Beyfortus) (CPB 1038, reviewed 2025-10-09)
Aetna's Clinical Policy Bulletin 1038 covers nirsevimab-alip (Beyfortus) for preventing lower respiratory tract disease caused by RSV. Aetna considers a single intramuscular injection medically necessary when the ACIP recommendations and the listed criteria are met, including for infants less than 8 months old born during or entering their first RSV season and for children 8 to 11 months old at increased risk for severe disease during their first RSV season. Aetna considers all other indications experimental, investigational, or unproven.
Aetna · Identified Aug 16, 2026Medium impact
Metreleptin (Myalept) (CPB 0882, reviewed 2026-07-10)
Aetna requires precertification for metreleptin (Myalept) for all participating providers and members in applicable plan designs. Aetna considers metreleptin medically necessary for congenital or acquired generalized lipodystrophy when the initial approval criteria are met, and considers it experimental, investigational, or unproven for partial lipodystrophy, HIV-related lipodystrophy, generalized obesity not associated with generalized lipodystrophy, and liver disease including metabolic dysfunction associated steatohepatitis (MASH). Continuation of therapy is medically necessary when the member has improved from baseline in metabolic control and continues dietary modifications along with regular exercise.
Aetna · Identified Aug 16, 2026Medium impact
Meningococcal Vaccines (CPB 0356, reviewed 2026-05-22)
Aetna considers the MenACWY, MenB and MenABCWY meningococcal vaccines medically necessary when they follow ACIP recommendations. Routine MenACWY is covered for adolescents aged 11 through 18, MenB is covered for members 10 years of age or older with listed risk factors and for healthy adolescents and young adults aged 16 through 23 based on shared clinical decision-making, and MenABCWY may be used when both MenACWY and MenB are indicated at the same visit. Meningococcal vaccine for all other indications, and saliva testing of antibody levels, are considered experimental, investigational, or unproven.
Aetna · Identified Aug 15, 2026Medium impact
Ibalizumab-uiyk (Trogarzo) (CPB 0936, reviewed 2025-12-30)
Aetna considers ibalizumab-uiyk (Trogarzo) medically necessary for use in combination with an antiretroviral regimen in heavily treatment-experienced adults with multidrug resistant (MDR) HIV-1 infection who are failing current antiretroviral regimen. The criteria require age 18 or older, a viral load greater than 1,000 copies/mL, documented resistance to at least one antiretroviral medication from each of three classes (NRTI, NNRTI and PI) as measured by resistance testing, and at least 6 months of antiretroviral treatment with failure or recent failure (in the last 8 weeks). Aetna considers ibalizumab-uiyk experimental, investigational, or unproven for all other indications.
Aetna · Identified Aug 15, 2026Medium impact
Immune Globulins for Post-Exposure Prophylaxis (CPB 0544, reviewed 2025-12-23)
Reviewed 2025-12-23, Aetna Clinical Policy Bulletin 0544 covers immune globulin products for post-exposure prophylaxis and treatment, including hepatitis B, cytomegalovirus, Rho(D), rabies, varicella zoster, tetanus, measles, rubella, vaccinia, and botulism immune globulins. For each product the policy lists the indications it considers medically necessary and states that all other indications are experimental, investigational, or unproven. Continuation of therapy is considered medically necessary for all members, including new members, who meet the initial criteria. Immune globulin intramuscular injection (GamaSTAN) requires precertification.
Aetna · Identified Aug 15, 2026Medium impact
Hematopoietic Colony-Stimulating Factors (CSFs) (CPB 0055, reviewed 2026-07-16)
Aetna's Clinical Policy Bulletin 0055 addresses hematopoietic colony-stimulating factors (CSFs) for commercial medical plans, and Medicare criteria are in the Medicare Part B Criteria. Precertification is required for long-acting G-CSF products (including Neulasta and Rolvedon), short-acting G-CSF products (including Neupogen and Granix) and Leukine (sargramostim) in applicable plan designs. Aetna considers short-acting G-CSF products medically necessary for prevention or treatment of febrile neutropenia, and long-acting products for prevention of febrile neutropenia, in cancer members receiving myelosuppressive chemotherapy when the listed criteria are met, and considers all other indications, including use as adjunctive therapy to antibiotics in uncomplicated febrile neutropenia, experimental, investigational, or unproven.
Aetna · Identified Aug 15, 2026Medium impact
Hepatitis B Vaccine (CPB 0410, reviewed 2026-07-06)
Aetna considers hepatitis B vaccine medically necessary when it follows CDC ACIP recommendations for members with listed indications, including all infants, unvaccinated children and adolescents under 19, adults aged 19 to 59 who have not previously completed vaccination, and adults 60 and older with risk factors. Revaccination or booster doses are considered medically necessary in listed circumstances when anti-HBs is less than 10 mIU/mL, including infants born to HBsAg-positive mothers, persons on hemodialysis, and health care professionals with an anti-HBs level below that threshold. For persons with normal immune status who have been vaccinated, booster doses are considered not medically necessary. Aetna generally does not cover immunizations required for travel or because of work-related risk. The policy states that in December 2025 the CDC adopted shared clinical decision-making for hepatitis B vaccination of infants born to mothers who test negative for hepatitis B, and that existing recommendations remain unchanged for infants born to HBsAg-positive mothers or mothers with unknown status.
Aetna · Identified Aug 15, 2026Medium impact
Extended Ophthalmoscopy (CPB 0767, reviewed 2025-12-02)
Aetna considers extended ophthalmoscopy with a detailed retinal drawing (CPT 92201 and 92202) medically necessary for evaluation of the posterior portion of the eye after routine ophthalmoscopy for listed indications such as retinal detachment, diabetic retinopathy, macular degeneration, uncontrolled glaucoma or glaucoma suspect, and high axial length myopia of -6.00 diopters or less. It is not medically necessary when routine ophthalmoscopy showed normal clinical findings, and a repeat examination is medically necessary only when there is a change in signs, symptoms or condition for an indication that may progress. The service must add information not available from standard evaluation services or information that will demonstrably affect the treatment plan, and it is considered experimental, investigational or unproven for conditions such as optic neuritis, sickle cell disease and screening for retinoblastoma.
Aetna · Identified Aug 14, 2026Medium impact
Allogeneic Processed Thymus Tissue–agdc (Rethymic) (CPB 1055, reviewed 2025-12-23)
Aetna considers a single administration of allogeneic processed thymus tissue-agdc (Rethymic) medically necessary for immune reconstitution in members 18 years of age or younger with congenital athymia when all criteria are met. Aetna considers all other indications experimental, investigational, or unproven. Members with severe combined immunodeficiency (SCID), preexisting cytomegalovirus or HIV infection, or any prior thymus tissue transplantation or Rethymic treatment are not eligible.
Aetna · Identified Aug 14, 2026Medium impact
Ultrasound for Pregnancy (CPB 0199, reviewed 2026-03-24)
Detailed fetal anatomic ultrasound (CPT 76811) is medically necessary for listed indications, including known or suspected fetal anatomic or genetic abnormalities, pregnancies resulting from in vitro fertilization (IVF), obesity with a pre-pregnancy body mass index of 30 kg/m2 or more, known or suspected Zika virus exposure, and a previous pregnancy with a fetus that had an omphalocele or other ultrasound detectable congenital anomaly associated with an elevated risk of recurrence. Ultrasounds done solely to determine fetal sex or to give parents a view and photograph of the fetus are not medically necessary, and more than one detailed fetal anatomic ultrasound in the first trimester or more than one in the second semester is considered not medically necessary. A limited duplex scan (CPT 93976) is medically necessary for listed obstetric indications such as vaginal bleeding in the second or third trimester, suspected placenta accreta spectrum, and suspected placental abruption, while a complete duplex scan (CPT 93975) during pregnancy is considered experimental, investigational, or unproven, and 3D and 4D fetal ultrasounds are not supported because of a lack of evidence that they alter management over standard two-dimensional ultrasound.
Aetna · Identified Aug 14, 2026Medium impact
Cognitive Rehabilitation (CPB 0214, reviewed 2026-04-21)
Aetna considers cognitive rehabilitation medically necessary as adjunctive treatment of cognitive deficits when it is performed by a licensed health care professional within their scope of practice and all of the following are met: neuropsychological testing has been performed and its results will be used in treatment planning and directing rehabilitation strategies; the cognitive deficits were acquired from moderate to severe traumatic brain injury, brain surgery, stroke, or encephalopathy; a psychiatric evaluation by a licensed mental health provider has been received when there is a behavioral health concern or possible comorbid condition; the member can actively participate in a program (not comatose or in a vegetative state); and the member is expected to make significant cognitive improvement. Cognitive rehabilitation is considered experimental, investigational or unproven for indications including mild traumatic brain injury (including sports-related concussion), dementia, long COVID, multiple sclerosis, ADHD, autism spectrum disorders, coma stimulation, and virtual reality therapy for acquired cognitive disorders. Outpatient cognitive rehabilitation coverage is subject to applicable benefit plan terms and limitations for physical and occupational therapy.
Aetna · Identified Aug 14, 2026Medium impact
Diagnosis of Vaginitis (CPB 0643, reviewed 2025-12-15)
Aetna considers several vaginitis tests medically necessary for women with symptoms of vaginitis, including nucleic acid amplification or DNA probe assays for trichomonas, Candida and Gardnerella for members with dysuria or symptoms of vaginitis, sialidase activity testing such as the BVBlue test, and pH and amine testing of vaginal fluid. Screening for Trichomonas vaginalis is considered medically necessary for women with risk factors such as HIV-positive status, new or multiple partners, a history of sexually transmitted diseases, exchange of sex for payment, injection drug use, or high-prevalence settings such as STD clinics and correctional facilities. A Pap smear for the diagnosis of Candida vulvo-vaginitis, routine screening for Candida and Gardnerella in asymptomatic women, the uBiome SmartJane screen, and the 27-organism vaginal pathogen panel from Bridge Diagnostics are considered experimental, investigational, or unproven because their effectiveness has not been established.
Aetna · Identified Aug 13, 2026Medium impact
Pharmacogenetic and Pharmacodynamic Testing (CPB 0715, reviewed 2025-12-03)
Aetna Clinical Policy Bulletin 0715 (reviewed 2025-12-03) sets coverage rules for pharmacogenetic and pharmacodynamic testing, listing the tests it considers medically necessary for specific drugs and indications, including EGFR, BRAF, KRAS, BRCA, ALK, DPYD, CYP2C19, CYP2D6, HLA-B*1502 and HLA-B*5701 testing. It considers multi-gene pharmacogenetics panels and many other listed tests experimental, investigational or unproven, and it considers several FoundationOne, Guardant360 CDx and oncoReveal panels not medically necessary for particular indications because there is no proven advantage over targeted testing for those indications. This is so check current applicability with Aetna before relying on it.
Aetna · Identified Aug 13, 2026Medium impact
Enfuvirtide (Fuzeon) (CPB 0671, reviewed 2026-03-25)
Aetna covers enfuvirtide (Fuzeon) for commercial medical plans in treatment of HIV-1 infection when the member has viremia despite 3 or more prior months of therapy with at least one appropriate regimen, or has viremia and documented resistance or intolerance to at least one appropriate regimen. Continuation is covered when the member has had a positive or stable virologic response to enfuvirtide. Aetna considers enfuvirtide experimental, investigational, or unproven for treatment-naive HIV-infected persons and for treatment of COVID-19.
Aetna · Identified Aug 12, 2026Medium impact
Onasemnogene Abeparvovec (Zolgensma and Itvisma) (CPB 0953, reviewed 2026-08-10)
Aetna's clinical policy bulletin covers onasemnogene abeparvovec (Zolgensma and Itvisma) for commercial medical plans and requires precertification of all Aetna participating providers and members in applicable plan designs. Aetna considers Zolgensma medically necessary as a single-dose intravenous infusion for spinal muscular atrophy (SMA) when the member is less than 2 years of age, has a genetically confirmed diagnosis with bi-allelic SMN1 variants and 3 or fewer copies of SMN2, and meets the other listed criteria, and considers Itvisma medically necessary as a single intrathecal dose for SMA when the member is 2 to less than 18 years of age, had onset of signs and symptoms at 6 months of age or older, and meets the other listed criteria. Aetna considers both products experimental, investigational, or unproven for all other indications, and considers repeat administration of onasemnogene abeparvovec experimental, investigational, or unproven.
Aetna · Identified Aug 12, 2026Medium impact
Cabotegravir and Rilpivirine (Cabenuva) (CPB 0987, reviewed 2026-04-02)
Aetna Clinical Policy Bulletin 0987 covers cabotegravir and rilpivirine (Cabenuva) for commercial medical plans and states that precertification is required for Aetna participating providers and members in applicable plan designs. Aetna considers the injectable medically necessary for HIV-1 infection when the member is virologically suppressed (HIV-1 RNA under 50 copies per mL) on a stable antiretroviral regimen with no history of treatment failure and no known or suspected resistance to either drug, or when the member has viremia, a high risk of disease progression (CD4 count under 200 cells per microliter or AIDS-defining complications), cannot achieve or maintain suppression on oral therapy despite intensive adherence support, and the prescriber attests to discussing the risk of resistance. Continuation is medically necessary unless the member has two consecutive HIV-1 RNA levels of 200 copies per mL or more on the requested drug. All other indications are considered experimental, investigational or unproven.
Aetna · Identified Aug 12, 2026Medium impact
Axicabtagene Ciloleucel (Yescarta) (CPB 0924, reviewed 2026-03-13)
Aetna considers axicabtagene ciloleucel (Yescarta) medically necessary for B-cell lymphoma indications listed in the policy, including DLBCL arising from follicular lymphoma, follicular lymphoma after two or more lines of systemic therapy, marginal zone lymphomas, pediatric primary mediastinal large B-cell lymphoma, and relapsed or refractory primary central nervous system lymphoma as a single agent, when the listed criteria are met. Aetna considers it experimental, investigational, or unproven for acute lymphoblastic leukemia, indolent non-Hodgkin lymphomas other than the listed exceptions, mantle cell lymphoma, and solid tumors, and considers repeat administration experimental, investigational, or unproven. Yescarta requires precertification for all Aetna participating providers and members in applicable plan designs.
Aetna · Identified Aug 12, 2026Medium impact
Adoptive Immunotherapy and Cellular Therapy (CPB 0641, reviewed 2025-10-01)
Aetna's Clinical Policy Bulletin 0641 considers adoptive immunotherapy using tumor-infiltrating lymphocytes or IL-2-activated LAK cells, and a broad list of cellular therapies, experimental, investigational or unproven for the indications it names. Those indications include most cancers, Alzheimer disease, COVID-19, heart failure, ischemic heart disease, orthopedic and musculoskeletal disorders, and minimization of general immunosuppression in kidney transplant recipients. The policy names exceptions for lifileucel (Amtagvi) in melanoma and afamitresgene autoleucel (Tecelra) in synovial sarcoma, and it lists CAR T-cell therapy for solid tumors and virus-specific T-cell lymphocyte therapy for viral infections among the unproven uses.
Aetna · Identified Aug 12, 2026Medium impact
Vitamin D Assay (CPB 0945, reviewed 2025-12-23)
Aetna considers measurements of serum 25-hydroxyvitamin D experimental, investigational, or unproven for routine preventive screening. CPT codes 0038U, 82306 and 82652 are covered if selection criteria are met, and ICD-10 codes covered if selection criteria are met include vitamin D deficiency (E55.0 to E55.9), chronic kidney disease (N18.1 to N18.9) and osteoporosis (M80.00xA to M81.8). ICD-10 codes not covered for the indications listed in the policy include malignant neoplasms of the breast (C50.011 to C50.929) and prostate (C61), diabetes mellitus (E08.00 to E13.9), Alzheimer's disease (G30.0 to G30.9) and screening encounters for malignant neoplasms (Z12.0 to Z12.9).
Blue Cross & Blue Shield of Mississippi · Identified Jun 20, 2026Medium impact
Free Testosterone Testing
Serum free testosterone (CPT 84402) is medically necessary to distinguish a sex hormone-binding globulin (SHBG) abnormality from hypogonadism in obese males with symptoms of hypogonadism when total testosterone is low, to diagnose hyperandrogenism in symptomatic females, and in patients with a medical diagnosis that may increase or decrease SHBG levels. It is not medically necessary to diagnose testosterone deficiency in non-obese males with symptoms of hypogonadism, or when performed for screening of asymptomatic patients. Free testosterone should be performed by equilibrium dialysis, and free testosterone measured by an analog method should never be ordered.
Independence Blue Cross · Effective Mar 4, 2026Low impact
06.02.09g, Human Immunodeficiency Virus (HIV) Genotyping and Phenotyping (Independence Administrators)
This is a routine annual policy reissue with no substantive changes to HIV genotyping and phenotyping coverage criteria. The only modification is a disclaimer language update effective 03/04/2026 that excludes members whose groups have enrolled in the UM vendor program from this policy's applicability.
Independence Blue Cross · Effective Oct 1, 2025Low impact
MA05.021c, Injectable Dermal Fillers for Cosmetic Procedures
This policy reissue updates ICD-10 diagnosis coding for Injectable Dermal Fillers (MA05.021c) effective 10/01/2025. The code E88.1 (Lipodystrophy, not elsewhere classified) has been deleted and replaced with E88.14 (HIV-associated lipodystrophy) to align with annual ICD-10 code updates. No coverage criteria, billing codes, or medical necessity requirements have changed. Billing teams must update internal coding references to use the new ICD-10 code for HIV-associated lipodystrophy claims.
Independence Blue Cross · Effective Oct 1, 2025Low impact
MA05.021c, Injectable Dermal Fillers for Cosmetic Procedures
Independence Blue Cross updated policy MA05.021c for injectable dermal fillers effective 10/01/2025, replacing deleted ICD-10 code E88.1 (Lipodystrophy, not elsewhere classified) with E88.14 (HIV-associated lipodystrophy). The policy was reissued on 04/01/2026 with no substantive changes to coverage criteria. Coverage remains limited to Sculptra® and Radiesse® for HIV-associated facial lipodystrophy when depression is a significant contributor.
Aetna · Identified Sep 29, 2026Low impact
Bio-Surgery: Medicinal Leech Therapy and Medical Maggots (CPB 0556, reviewed 2026-09-01)
Aetna's bio-surgery policy (CPB 0556, reviewed September 1, 2026) sets when medicinal leech therapy and medical maggots (bagged larval therapy) are covered, mainly for specific chronic wounds, flap and replant salvage. It lists many other uses, including knee and thumb osteoarthritis, low back pain and burns, as experimental, and the source gives a review date but no effective date.

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FREQUENTLY ASKED QUESTIONS

What insurance policy changes affect code B20?

There are 50 tracked policy changes affecting code B20, including updates from Aetna, Independence Blue Cross, Blue Cross & Blue Shield of Mississippi. Each change may modify coverage criteria, reimbursement rates, or prior-authorization requirements.

Which payers have updated policy for code B20?

Payers that have issued tracked updates for code B20 include: Aetna, Independence Blue Cross, Blue Cross & Blue Shield of Mississippi.

How do I get notified when code B20 policy changes?

Create a free account at PolicyChanges.app and save a search filtered to code B20. You will get an email when new policy changes reference this code: daily or weekly, your choice, on every plan.

Why do payers change policies for code B20?

Payers revise policies for individual billing codes to align with updated clinical guidelines, CMS rule changes, fraud and abuse prevention measures, or network cost-management goals. Changes can affect medical necessity criteria, place-of-service restrictions, bundling rules, or whether a code requires prior authorization.

All billing codes J3590 C9399 J3490 99215 99213 99202

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Clesrovimab-cfor (Enflonsia) (CPB 1088, reviewed 09-2025-10)

MA08.108g, Polatuzumab vedotin-piiq (Polivy®)

MA08.139e, Loncastuximab tesirine-lpyl (Zynlonta®)

08.01.59g, Polatuzumab vedotin-piiq (Polivy®)

08.00.59e, Loncastuximab tesirine-lpyl (Zynlonta®)

MA08.011i, Erythropoiesis Stimulating Agents (ESAs)

Immunoglobulin Therapy

08.00.75r, Erythropoiesis-Stimulating Agents (ESAs)

Etuvetidigene Autotemcel (Waskyra) (CPB 1097, reviewed 2026-10-05)

Clesrovimab-cfor (Enflonsia) (CPB 1088, reviewed 2026-10-09)

Human Growth Hormone and Insulin-like Growth Factor-1

MA05.021b, Injectable Dermal Fillers for Cosmetic Procedures

Axicabtagene Ciloleucel (Yescarta) (CPB 0924, reviewed 2026-10-09)

Immune Globulins for Post-Exposure Prophylaxis (CPB 0544, reviewed 2026-10-07)

Marnetegragene Autotemcel (Kresladi) (CPB 1102)

Pegzilarginase-nbln (Loargys) (CPB 1101)

HIV Testing (CPB 0542, reviewed 2026-08-28)

Diagnosis of Vaginitis (CPB 0643, reviewed 2026-09-25)

Clesrovimab-cfor (Enflonsia) (CPB 1088)

HIV Drug Susceptibility and Resistance Tests (CPB 0316, reviewed 2026-05-21)

Varicella and Herpes Zoster Vaccines (CPB 0115, reviewed 2026-03-19)

Obinutuzumab (Gazyva) (CPB 0877, reviewed 2026-06-05)

HIV Testing (CPB 0542, reviewed 2025-11-26)

Hepatitis Screening (CPB 0835, reviewed 2025-12-09)

Flow Cytometry, Ektacytometry, DNA Ploidy, and S-phase Fraction (CPB 0351, reviewed 2026-05-21)

Nebulizers (CPB 0065, reviewed 2026-03-18)

Nirsevimab-alip (Beyfortus) (CPB 1038, reviewed 2025-10-09)

Metreleptin (Myalept) (CPB 0882, reviewed 2026-07-10)

Meningococcal Vaccines (CPB 0356, reviewed 2026-05-22)

Ibalizumab-uiyk (Trogarzo) (CPB 0936, reviewed 2025-12-30)

Immune Globulins for Post-Exposure Prophylaxis (CPB 0544, reviewed 2025-12-23)

Hematopoietic Colony-Stimulating Factors (CSFs) (CPB 0055, reviewed 2026-07-16)

Hepatitis B Vaccine (CPB 0410, reviewed 2026-07-06)

Extended Ophthalmoscopy (CPB 0767, reviewed 2025-12-02)

Allogeneic Processed Thymus Tissue–agdc (Rethymic) (CPB 1055, reviewed 2025-12-23)

Ultrasound for Pregnancy (CPB 0199, reviewed 2026-03-24)

Cognitive Rehabilitation (CPB 0214, reviewed 2026-04-21)

Diagnosis of Vaginitis (CPB 0643, reviewed 2025-12-15)

Pharmacogenetic and Pharmacodynamic Testing (CPB 0715, reviewed 2025-12-03)

Enfuvirtide (Fuzeon) (CPB 0671, reviewed 2026-03-25)

Onasemnogene Abeparvovec (Zolgensma and Itvisma) (CPB 0953, reviewed 2026-08-10)

Cabotegravir and Rilpivirine (Cabenuva) (CPB 0987, reviewed 2026-04-02)

Axicabtagene Ciloleucel (Yescarta) (CPB 0924, reviewed 2026-03-13)

Adoptive Immunotherapy and Cellular Therapy (CPB 0641, reviewed 2025-10-01)

Vitamin D Assay (CPB 0945, reviewed 2025-12-23)

Free Testosterone Testing

06.02.09g, Human Immunodeficiency Virus (HIV) Genotyping and Phenotyping (Independence Administrators)

MA05.021c, Injectable Dermal Fillers for Cosmetic Procedures

MA05.021c, Injectable Dermal Fillers for Cosmetic Procedures

Bio-Surgery: Medicinal Leech Therapy and Medical Maggots (CPB 0556, reviewed 2026-09-01)

What insurance policy changes affect code B20?

Which payers have updated policy for code B20?

How do I get notified when code B20 policy changes?

Why do payers change policies for code B20?