CommercialCoverageHigh impact
Endoscopic Ultrasonography (CPB 0446, reviewed 2026-07-22)
Aetna·Gastroenterology, Pulmonology, Oncology +3 more·Medical Policy
Effective date
Jul 22, 2026
We identified it
Aug 14, 2026
Summary
Aetna CPB 0446 (reviewed 2026-07-22) clarifies medical necessity criteria for Endoscopic Ultrasonography (EUS), establishing 16 covered indications and explicitly identifying 8 experimental/investigational uses that will be denied. Key covered procedures include diagnostic imaging for biliary/pancreatic/GI pathology, tissue sampling, tumor staging, and therapeutic interventions. Experimental procedures (EUS-elastography, certain ablation therapies, ethanol injection for PNENs) must not be billed as covered services.
Action Required
By 2026-08-22: Billing team must update billing software rules and prior authorization protocols for all EUS procedures (CPT 31652-31654, 43231-43259, 44406-44407, 45341-45392, 76975, 64530) to enforce the 16 covered indications listed in Section I of CPB 0446. Immediately flag and deny claims for experimental procedures: EUS-elastography (CPT 76981, 76983), EUS-guided ethanol injection for PNENs (CPT 43253 for this indication), EUS-guided ablation therapies, EUS-guided interstitial brachytherapy (0395T, 77770-77778), and hepatic portosystemic pressure gradient measurement (C9768). Configure encounter forms and prior auth workflows to require documentation of specific medical necessity criteria (e.g., 'common bile duct stones', 'pancreatic mass evaluation', 'tumor staging'). Train clinical staff to validate EUS requests against the 16 approved indications before submission. Failure to enforce this policy will result in automatic claim denials and potential compliance violations.