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Blood and Adipose Tissue Derived Products for Selected Indications (CPB 0784, reviewed 2025-11-19)
Aetna·Orthopedics, Sports Medicine, Pain Management +7 more·Medical Policy
Effective date
Nov 19, 2025
We identified it
Aug 12, 2026
Summary
Aetna's CPB 0784 policy (effective 2025-11-19) classifies blood and adipose tissue-derived products as experimental, investigational, or unproven for a comprehensive list of indications. This means procedures using platelet-rich plasma (PRP), platelet-poor plasma (PPP), autologous blood injections, adipose-derived stem cells, and related biologics are NOT covered for specified conditions including rotator cuff tears, knee osteoarthritis, tendinopathies, and numerous orthopedic/soft tissue conditions. Billing teams must deny claims for these procedures when billed with listed indications and CPT/HCPCS codes.
Action Required
Immediately effective 2025-11-19: Billing team must implement claim denial logic in billing software for all CPT/HCPCS codes listed in CPB 0784 when billed with experimental indications including rotator cuff tears, knee osteoarthritis, tendinopathies, plantar fasciitis, Achilles tendinopathy, ankle sprains, ACL surgery, avascular necrosis, osteoarthritis, and all other indications specified in the policy. Update claim scrubber rules to automatically deny or hold for manual review any claim for CPT 0232T, 0489T, 0490T, 0565T, 0566T, 0717T, 0718T, 15771-15774, G0460, and G0465 for Aetna Commercial and Aetna Medicare Advantage plans. Create provider notification summarizing non-covered procedures and indications. Update encounter forms and surgery scheduling templates to alert providers that PRP, adipose stem cell, autologous blood, and related biologic injections are not covered by Aetna for these conditions. Inform patients of non-coverage status prior to service delivery to avoid surprise billing. Claims submitted without prior awareness will be denied and require patient notification under No Surprises Act compliance.