CommercialCoverageHigh impact
Drug-Eluting Stents (CPB 0621, reviewed 2026-02-25)
Aetna·Cardiology, Vascular Surgery, Radiology +1 more·Pharmacy
Effective date
Feb 25, 2026
We identified it
Aug 14, 2026
Summary
Aetna's updated Drug-Eluting Stents policy (CPB 0621, reviewed 2026-02-25) clarifies coverage for FDA-approved drug-eluting stents in coronary and peripheral applications while explicitly designating biodegradable polymer stents, antibody-coated stents, and multiple non-coronary indications as experimental/investigational. Billing teams must ensure claims for covered stent types meet specific medical necessity criteria and route non-covered indications for prior authorization or denial.
Action Required
By 2026-02-25: Billing team must implement the following changes in billing software and claim submission processes: (1) For CPT codes 92928–92945, 0913T, 0914T, and C9600–C9606 (coronary stent placement): Ensure claims include documentation verifying one of the following medical necessity criteria: (a) acute coronary syndrome/stable angina with ≥50% left main stenosis, (b) refractory/contraindicated angina with ≥70% stenosis in ≥1 artery, or (c) ≥50% stenosis with FFR ≤0.80. Reject or flag claims lacking this documentation for provider inquiry. (2) For stent type verification: HCPCS codes C1874 and C1875 are covered ONLY for everolimus, paclitaxel, sirolimus, or zotarolimus-eluting stents. Do NOT reimburse biodegradable polymer stents, antibody-coated stents, or magnetically-coated bioabsorbable stents under these codes. Route claims for these stent types to medical review or denial. (3) For peripheral vascular stents (CPT 37224–37227): Eluvia stents are covered for superficial femoral artery (SFA) and proximal popliteal artery disease only; Zilver PTX stents are covered for femoro-popliteal artery disease only. Deny or request prior authorization for Eluvia use in iliac artery stenosis. (4) For all non-covered indications (intracranial stenosis, carotid stenosis, renal artery stenosis, venous stenosis, pancreato-biliary disease, pulmonary vein stenosis, etc.): Pre-authorize via prior auth request or automatically deny with explanation of benefits (EOB) citing investigational/experimental status per CPB 0621. (5) Encounter forms and provider billing guidelines must be updated to list covered stent types and medical necessity criteria; distribute to cardiology and interventional radiology departments. (6) Do NOT separately reimburse IVUS or OCT imaging (integral to procedure per policy). Claims submitted with separate codes for imaging will be bundled or denied. Failure to implement these changes will result in improper denials, provider disputes, and compliance issues with Aetna coverage rules.