CommercialCoverageHigh impact
Procalcitonin (PCT) (CPB 0771, reviewed 2025-11-13)
Aetna·Critical Care, Infectious Disease, Pulmonology +7 more·Medical Policy
Effective date
Nov 13, 2025
We identified it
Aug 13, 2026
Summary
Aetna updated its Procalcitonin (PCT) medical policy (CPB 0771, effective 2025-11-13) to define covered and non-covered uses of CPT code 84145. PCT testing is covered only for risk-stratifying febrile infants aged 8-60 days and for initiating/discontinuing antibiotics in ICU patients and hospitalized patients with respiratory infections. All other uses—including sepsis diagnosis, pneumonia differentiation, cardiac surgery complications, and numerous other clinical scenarios—are classified as experimental/investigational and not covered.
Action Required
By 2025-11-13: Billing team must immediately update billing system edits to restrict CPT 84145 (Procalcitonin) to ONLY two covered scenarios: (1) febrile infants aged 8-60 days for bacterial infection risk-stratification, and (2) ICU patients or hospitalized patients with respiratory infections for antibiotic initiation/discontinuation. All other clinical indications must be denied at claim submission or flagged for medical necessity review before billing. Update claim scrubbing logic to cross-reference diagnosis codes against the extensive non-covered list (includes A15.0-A15.9, A40.0-A49.9, G00.0-G00.9, J12.0-J15.9, K35.200-K37, N10, and 50+ others listed in policy). Providers and clinical staff must be notified that PCT testing for sepsis diagnosis, pneumonia differentiation, diabetic foot ulcer assessment, post-operative complications, and most other uses will NOT be covered effective immediately. Failure to implement these restrictions will result in claim denials and potential recoupment of previously paid claims for non-covered indications.