CommercialCoverageHigh impact
Transplant Immune Cell Function Assays (CPB 0773, reviewed 2025-12-23)
Aetna·Transplant Surgery, Nephrology, Cardiothoracic Surgery +3 more·Medical Policy
Effective date
Dec 23, 2025
We identified it
Aug 12, 2026
Summary
Aetna has updated its transplant immune cell function assay policy (CPB 0773) to establish narrow coverage for the ImmuKnow Assay ONLY for adjudicating over-immunosuppression in transplant recipients with co-morbid infection or cancer. All other immune cell function assays and indications—including CMV risk stratification, rejection prediction, and post-transplant monitoring—are now classified as experimental/investigational and not covered. Billing teams must immediately stop billing these assays for non-covered indications to prevent claim denials.
Action Required
Immediately (effective 2025-12-23): Billing team must update claims processing rules and denial protocols in billing software to reflect the severe coverage restrictions on transplant immune cell function assays. SPECIFIC ACTIONS: (1) Configure system to DENY claims for CPT 86352, 0118U, 0581U, and 81560 UNLESS the claim includes ICD-10 codes A00.0-B99.9 (infectious diseases) OR C00.0-D09.9 (malignant neoplasms, excluding renal cell carcinoma C64.x) AND documentation proves the test is for adjudicating over-immunosuppression in transplant recipients with these co-morbidities. (2) Create automated denial rules rejecting all claims for these codes paired with the following ICD-10 codes: B25.8 (CMV), D47.z1 (PTLD), D89.810-D89.813 (GVHD), K50.00-K51.919 (IBD), M32.14 (lupus nephritis), T86.10-T86.899 (transplant complications), Z48.21-Z94.9 (transplant aftercare/status). (3) Update Prior Authorization (PA) request templates to require medical documentation demonstrating over-immunosuppression AND concurrent infection or cancer diagnosis before any approval. (4) Communicate to all providers that ImmuKnow (CPT 86352) is now ONLY covered for over-immunosuppression assessment in transplant recipients with active infection or cancer; all other uses (CMV monitoring, rejection prediction, post-transplant surveillance) are experimental and will be denied. (5) Update fee schedules to reflect $0 reimbursement for T-SPOT.CMV, QuantiFERON-CMV, IFN-γ ELISpot assays, donor-derived cell-free DNA testing (0118U), and non-HLA autoantibody testing (0581U) for ALL indications. Providers: Document specific clinical indication (over-immunosuppression + infection OR cancer) on all claims for CPT 86352 or expect denial. Failure to implement these changes will result in high claim denial rates and revenue loss.