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S3852

PAYER POLICY CHANGES

S3852 Insurance Policy Changes

HCPCS S3852 is officially defined as "Dna analysis for apoe epsilon 4 allele for susceptibility to alzheimer's disease." HCPCS S3852 is referenced in 6 tracked payer policy changes from Aetna and Blue Cross & Blue Shield of Mississippi. For billers and coders, staying current on payer-specific coverage criteria, reimbursement rules, and prior-authorization requirements for HCPCS S3852 is critical to clean claim submission. Each entry below links to the full policy analysis with effective dates and action steps.

Aetna · Identified Nov 3, 2026High impact
Lecanemab-irmb (Leqembi) (CPB 1026, reviewed 2026-10-29)
Aetna's clinical policy bulletin for lecanemab-irmb (Leqembi), reviewed October 29, 2026, sets commercial plan criteria for initial authorization and 12-month continuation, including staging, cognitive score thresholds, MRI monitoring for ARIA, ApoE ε4 genotype testing, and registry participation. Precertification is required by Aetna for applicable plan designs, and site-of-care utilization management applies to infusions. The practice should align prior-auth requests, documentation, and charge entry for Leqembi with these criteria.
Aetna · Identified Aug 17, 2026Medium impact
Aducanumab-avwa (Aduhelm) (CPB 0996, reviewed 2025-12-09)
Aetna considers aducanumab-avwa (Aduhelm) medically necessary for treatment of Alzheimer's disease for commercial medical plans when the initial approval criteria are met, and considers all other indications experimental, investigational or unproven. Aduhelm requires precertification, and Aduhelm was discontinued in November 2024.
Aetna · Identified Aug 16, 2026Medium impact
Lecanemab-irmb (Leqembi) (CPB 1026, reviewed 2026-01-27)
Aetna Clinical Policy Bulletin 1026 covers lecanemab-irmb (Leqembi) for commercial medical plans, and Medicare criteria are in a separate document. Aetna considers Leqembi medically necessary for Alzheimer's disease when the member is 50 or older, or younger with an APP, PSEN1 or PSEN2 genetic mutation or other clinical documentation to support early onset AD, and has Clinical Stage 3 or Clinical Stage 4 AD with objective cognitive impairment at baseline. Baseline scores must be taken within 12 months before treatment starts: CDR-Global Score of 0.5 or 1, MMSE of 21 to 30, or MoCA of 16 or greater. Amyloid pathology must be confirmed by PET or by a lumbar puncture CSF result, and a recent brain MRI within one year before starting is required. Members with a suspected non-AD neurodegenerative cause of cognitive impairment, more than 4 cerebral microbleeds, cortical superficial siderosis, a major vascular contribution confirmed by MRI, a cerebral contusion, encephalomalacia, brain aneurysm, CNS infection or brain tumor, a TIA, stroke, uncontrolled hypertension or seizure in the past 12 months, an uncontrolled bleeding disorder, or an immunologic disorder requiring immunoglobulins, monoclonal antibodies, immunosuppressants or plasmapheresis are excluded. Continuation is covered for 12 months after the initial 7-month approval period, and again for 12 months after the initial 19 months of therapy when the member shows a positive clinical response.
Aetna · Identified Aug 13, 2026Medium impact
Donanemab-azbt (Kisunla) (CPB 1066, reviewed 2025-10-17)
Aetna considers Kisunla (donanemab-azbt) medically necessary for Alzheimer's disease when the member is 50 or older, or is younger with an APP, PSEN1 or PSEN2 mutation or other documentation of early onset AD, is in Clinical Stage 3 or 4, has objective cognitive impairment, and has amyloid pathology confirmed by PET or by cerebrospinal fluid results. The initial criteria also require a brain MRI within one year before treatment, ApoE e4 genotype testing, a baseline CDR-GS of 0.5 or 1, MMSE of 21 to 30, or MoCA of 16 or greater within 12 months of treatment initiation, and participation in a provider-enrolled registry such as ALZ-NET. Anticoagulants may not be used with the drug, any antiplatelet agent must be used as monotherapy at a standard therapeutic dose, and precertification is required.
Aetna · Identified Aug 12, 2026Medium impact
Alzheimer's Disease Tests (CPB 0349, reviewed 2026-08-04)
Aetna considers lumbar puncture CSF tests medically necessary for diagnosing or managing Alzheimer's disease when criteria are met and AD is suspected in mild cognitive impairment. Covered CSF patterns are elevated phosphorylated tau and/or total tau with reduced AB42, a low AB42/AB40 ratio, an elevated P-tau/AB42 ratio, or an elevated T-tau/AB42 ratio, and brain MRI is covered for members on Aduhelm, Leqembi, or Kisunla to indicate AD within one year before starting therapy or to evaluate for amyloid-related imaging abnormalities (ARIA) before specified doses. The following are listed as experimental, investigational, or unproven for AD diagnosis or assessment: plasma amyloid beta 40 and 42, plasma tau including p-tau217, plasma glial fibrillary acidic protein, the PrecivityAD2 test, the Syn-One test, and artificial intelligence and machine learning applications.
Blue Cross & Blue Shield of Mississippi · Identified Jun 20, 2026Medium impact
Genetic Testing for Alzheimer Disease
Since the 06/15/2025 policy update, genetic testing for the APOE gene is considered medically necessary to guide initiation or management of an FDA-approved amyloid-beta targeting therapy in individuals with mild cognitive impairment or mild dementia associated with Alzheimer disease, where it was previously investigational. Genetic testing for the risk assessment of Alzheimer disease in asymptomatic individuals is considered investigational in all other situations. Targeted testing for a known familial variant in the PSEN or APP genes may be considered medically necessary in an asymptomatic individual when a first- or second-degree relative has a known familial variant and the results will inform reproductive decision making.

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REFERENCE DATA

Payers with rules17

Payers requiring prior auth17

Anthem BCBS · Effective November 1, 2026
Prior authorization required
Anthem Local PPO Precertification/Prior Authorization List (California | Anthem Blue Cross | Commercial)
BCBS Arizona · Effective October 1, 2026
Prior authorization required in some cases
AZ Blue Standard Prior Authorization Requirements Code List (Updated 10/01/2026)
Excellus BlueCross BlueShield · Effective October 1, 2026
Prior authorization required
Excellus BCBS utilization management standard clinical review preauthorization list

FREQUENTLY ASKED QUESTIONS

Does Ambetter require prior authorization for S3852?

Ambetter lists S3852 on Ambetter from Arizona Complete Health CMS-0057-F prior authorization requirements for exchange plans (list dated December 31, 2025). Verify with the payer before scheduling.

Does AmeriHealth Caritas require prior authorization for S3852?

AmeriHealth Caritas lists S3852 on AmeriHealth Caritas Louisiana prior authorization service list for medicaid managed plans. Verify with the payer before scheduling.

Does Anthem BCBS require prior authorization for S3852?

Anthem BCBS lists S3852 on Anthem Local PPO Precertification/Prior Authorization List (California | Anthem Blue Cross | Commercial) for commercial plans (list dated November 1, 2026). Verify with the payer before scheduling.

Does BCBS Arizona require prior authorization for S3852?

BCBS Arizona lists S3852 on AZ Blue Standard Prior Authorization Requirements Code List (Updated 10/01/2026) for commercial plans, with conditions (list dated October 1, 2026). Verify with the payer before scheduling.

Does BCBS Illinois require prior authorization for S3852?

BCBS Illinois lists S3852 on 2026 Commercial Outpatient Medical Surgical Prior Authorization Codes for commercial plans, with conditions (list dated January 1, 2026). Verify with the payer before scheduling.

What insurance policy changes affect HCPCS S3852?

There are 6 tracked policy changes affecting HCPCS S3852, including updates from Aetna, Blue Cross & Blue Shield of Mississippi. Each change may modify coverage criteria, reimbursement rates, or prior-authorization requirements.

Which payers have updated policy for HCPCS S3852?

Payers that have issued tracked updates for HCPCS S3852 include: Aetna, Blue Cross & Blue Shield of Mississippi.

How do I get notified when HCPCS S3852 policy changes?

Create a free account at PolicyChanges.app and save a search filtered to HCPCS S3852. 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 HCPCS S3852?

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.

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Prior authorization lists, coverage criteria, NCCI edits and Medicare coverage articles for S3852 in one place.

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All billing codes J3590 C9399 J3490 99215 99213 99202

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Lecanemab-irmb (Leqembi) (CPB 1026, reviewed 2026-10-29)

Aducanumab-avwa (Aduhelm) (CPB 0996, reviewed 2025-12-09)

Lecanemab-irmb (Leqembi) (CPB 1026, reviewed 2026-01-27)

Donanemab-azbt (Kisunla) (CPB 1066, reviewed 2025-10-17)

Alzheimer's Disease Tests (CPB 0349, reviewed 2026-08-04)

Genetic Testing for Alzheimer Disease

Prior authorization required

Prior authorization required in some cases