CommercialCoverageHigh impact
Tumor Markers (CPB 0352, reviewed 2026-03-27)
Aetna·Oncology, Hematology, Pathology·Medical Policy
Effective date
Mar 27, 2026
We identified it
Aug 12, 2026
Summary
Aetna has updated its Tumor Markers Clinical Policy Bulletin (CPB 0352) effective 2026-03-27, establishing medical necessity criteria for somatic tumor marker testing across multiple cancer types and hematologic malignancies. This policy clarifies which tumor markers are covered versus experimental, requiring billing teams to verify medical necessity documentation before claim submission.
Action Required
IMMEDIATELY: Billing team must obtain and review the complete Aetna CPB 0352 policy document to identify all specific CPT/HCPCS codes for tumor marker testing. By 2026-03-27: (1) Update billing software to enforce prior authorization requirements for tumor marker tests based on Aetna's medical necessity criteria; (2) Create a verification checklist for providers documenting which cancer diagnosis/condition justifies each marker test (e.g., AFP for hepatocellular carcinoma only in specified risk groups, not all HCC cases); (3) Train billing and clinical staff that repeat tumor marker testing is considered experimental and will be denied unless medical necessity is documented; (4) Flag claims for markers tested on non-specified indications for manual review before submission; (5) Update encounter templates to require documentation of specific diagnosis codes matching approved indications. Failure to verify medical necessity per this policy will result in claim denials and require rework.