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AetnaAll Plans · Coverage · Medical Policy · Oncology, Genetics, Cardiology +7 moreMedium impact

Pharmacogenetic and Pharmacodynamic Testing (CPB 0715, reviewed 2025-12-03)

Effective date
Not stated in the notice
Identified
Aug 13, 2026

Summary

Aetna Clinical Policy Bulletin 0715 (reviewed 2025-12-03) sets coverage rules for pharmacogenetic and pharmacodynamic testing, listing the tests it considers medically necessary for specific drugs and indications, including EGFR, BRAF, KRAS, BRCA, ALK, DPYD, CYP2C19, CYP2D6, HLA-B*1502 and HLA-B*5701 testing. It considers multi-gene pharmacogenetics panels and many other listed tests experimental, investigational or unproven, and it considers several FoundationOne, Guardant360 CDx and oncoReveal panels not medically necessary for particular indications because there is no proven advantage over targeted testing for those indications. This is so check current applicability with Aetna before relying on it.

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What to do

Action · 7 steps
01Billing team: Before billing a listed test, confirm the member meets the selection criteria for that test's indication, because the policy covers the listed CPT and ICD-10 codes only when those criteria are met.
02For ctDNA MRD testing (Signatera) in muscle invasive bladder cancer, bill only when the initial test is done no earlier than 6 weeks after radical cystectomy, repeat tests come no more often than every 6 weeks, and testing stays within the first 12 months after cystectomy.
03For CYP2C19 genotyping (CPT 81225), the covered diagnoses are chronic ischemic heart disease codes I25.10 through I25.9, and the policy lists this test as not covered for fluoxetine.
04For DPYD gene variant testing (CPT 81232), the covered use is before fluoropyrimidine therapy with fluorouracil or capecitabine.
05For HLA-B*5701 screening before abacavir, the policy gives no specific CPT code and lists ICD-10 codes B20 and Z21.
06For FoundationOne CDx, FoundationOne Liquid CDx, Guardant360 CDx, oncoReveal and TruSight Oncology Comprehensive, check the indication first, since the policy considers those panels not medically necessary for listed indications in NSCLC, melanoma, ovarian and breast cancer, among others.
07Multi-gene pharmacogenetics panels such as GeneSight, RightMed and Genomind are listed as experimental, investigational or unproven, so confirm a panel is not one of the listed tests before billing it.

Codes mentioned

8272681225812268122781232813508135581381812108123581275812878124581120814018127281301812918443183789J9274J1304E71.520G12.21E75.22Z79.82B20Z21G10

Original notice

Pharmacogenetic and Pharmacodynamic Testing (CPB 0715, reviewed 2025-12-03)
aetna.com · Always check the source before changing claims.
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Related policy hubs

Aetna policiesOncologyGeneticsCardiologyNeurologyHematologyInfectious DiseasePulmonologyPsychiatryPain ManagementOB-GYNCode 82726Code 81225Code 81226Code 81227Code 81232Code 81350Code 81355Code 81381Code 81210Code 81235Code 81275Code 81287Code 81245Code 81120Code 81401Code 81272Code 81301Code 81291Code 84431Code 83789Code J9274Code J1304Code E71.520Code G12.21Code E75.22Code Z79.82Code B20Code Z21Code G10

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