CommercialCoverageHigh impact
Prostate Biopsy (CPB 0698, reviewed 2026-03-02)
Aetna·Urology, Oncology, Radiology +1 more·Medical Policy
Effective date
Mar 2, 2026
We identified it
Aug 14, 2026
Summary
Aetna updated its prostate biopsy medical necessity criteria (CPB 0698), effective immediately. The policy now specifies which biopsy techniques are covered (transperineal stereotactic saturation, TRUS-guided, and MRI-guided/fusion approaches) based on specific clinical indications, while designating several newer technologies (AI-based mapping, contrast-enhanced ultrasound, liquid biopsy, micro-ultrasound, and spectral analysis) as experimental and non-covered. Billing teams must update claim processing to enforce these new coverage rules and deny claims for non-covered techniques.
Action Required
By March 2, 2026: (1) Billing team must update the billing system to reflect Aetna's new coverage matrix for prostate biopsy codes. Configure claim editing rules to allow CPT 55706-55715, 55707-55709, 55711-55714 only when documented clinical criteria are met (prior negative biopsies with rising PSA, atypia, high-grade PIN, or appropriate MRI findings). (2) Configure system to DENY or hold for manual review claims for CPT 0443T (spectral analysis), CPT 0898T (AI mapping software), and any claims referencing experimental techniques (Unfold AI, Avenda Health, micro-ultrasound, contrast-enhanced ultrasound, liquid biopsy) with denial reason code 'Not Medically Necessary - Experimental.' (3) Update provider portal documentation templates and encounter forms to clearly indicate which biopsy types require prior authorization and the mandatory medical necessity criteria. (4) Train billing staff to verify ICD-10 diagnosis codes are limited to C61, D07.5, or N42.30-N42.39; reject claims with Z12.5 (screening) for saturation biopsies. (5) Configure that CPT 55700 requires prior auth; confirm which approach is being used before allowing payment. Failure to implement these rules will result in claim denials and potential compliance issues with Aetna Medicaid Advantage plans.