CommercialPrior AuthHigh impact
Pulmonary Hypertension Treatments and Selected Indications of Prostanoids (CPB 0184, reviewed 2025-09-08)
Aetna·Pulmonology, Cardiology, Pediatrics·Medical Policy
Effective date
Sep 8, 2025
We identified it
Aug 14, 2026
Summary
Aetna updated its pulmonary hypertension treatment policy (CPB 0184, effective 2025-09-08) to clarify coverage criteria for prostanoid therapies and the newly added sotatercept-csrk (Winrevair). The policy now requires precertification for all pulmonary arterial hypertension drugs and specifies strict diagnostic criteria (right heart catheterization results) and prescriber requirements (pulmonologist or cardiologist consultation mandatory). Billing teams must implement prior authorization workflows and ensure claims include documented diagnostic confirmation before submission.
Action Required
By September 8, 2025: (1) Billing team must implement mandatory prior authorization workflow for all pulmonary hypertension drug claims submitted to Aetna commercial plans. (2) Update claim submission requirements to verify precertification before billing—contact Aetna precertification line (866) 752-7021 (commercial) or fax (888) 267-3277 for all PAH drug requests. (3) Front desk/authorizations staff must ensure all pulmonary hypertension treatment requests include documented right heart catheterization results (mPAP >20 mmHg, PCWP ≤15 mmHg, PVR >2 Wood units) or Doppler echocardiogram for pediatric/infant cases before submitting for precertification. (4) Providers must confirm prescriber specialty (pulmonologist or cardiologist) on all orders—claims from non-qualifying specialties will be denied. (5) For sotatercept-csrk (Winrevair) specifically, billing team must verify member is already on PAH therapy from at least 2 of 5 drug classes (endothelin receptor antagonist, phosphodiesterase-5 inhibitor, soluble guanylate cyclase stimulator, prostacyclin analog, or prostacyclin receptor agonist) before requesting authorization. (6) Update EMR/EHR templates to require documentation of diagnostic criteria and current PAH drug regimen for all pulmonary hypertension cases. Failure to obtain precertification or submit required diagnostic documentation will result in claim denials.