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Organ Prolapse: Selected Procedures (CPB 0858, reviewed 2025-12-24)

Aetna·OB-GYN, General Surgery·Medical Policy
Effective date
Dec 24, 2025
We identified it
Aug 12, 2026
Days to comply

Summary

Aetna's updated Organ Prolapse policy (CPB 0858, effective 2025-12-24) establishes medical necessity coverage for five specific procedures including laparoscopic suture rectopexy, sacrocolpopexy, and tension-free vaginal tape surgery, while classifying ten additional procedures and technologies as experimental/investigational. Billing teams must update systems to deny claims for non-covered experimental procedures and ensure prior authorization documentation aligns with the five covered interventions.

Action Required

Action needed
By 2025-12-24: Billing team must update billing software to flag and deny claims for experimental procedures (biodegradable cog threads, biologic grafts, laser therapy, pectopexy, TENS therapy, vNOTES procedures, vaginal tactile imaging, genetic testing for prolapse). Verify that only CPT codes 57120, 57280, 57282, 57288, 57425 process as covered when paired with ICD-10 codes K62.2, K62.3, N81.0-N81.9. Implement system edits to reject CPT 0487T, 0552T, 57267/57284/57285 with biologic grafts, HCPCS A4556-A4595, C1781, E0720, E0730, G0283, S8948, and genetic testing codes (81400-81479) for organ prolapse indications. Update encounter templates to require documentation of medical necessity for covered procedures. Inform providers that claims for experimental procedures will be denied. Flag ICD-10 codes N39.41-N39.498, N95.2, R10.2-R10.24, R32, R39.81 as non-covered for this policy.

Affected Billing Codes

57120
57280
57282
57288
57425
57267
57284
57285
81400
81479
A4556
A4557
A4558
A4595
C1781
E0720
E0730
G0283
S8948
K62.2
K62.3
N81.0
N81.9
N39.41
N39.498
N95.2
R10.2
R10.24
R32
R39.81