All PlansPrior AuthMedium impact
Epilepsy Surgery (CPB 0394, reviewed 2026-06-23)
Aetna·Neurosurgery, Neurology, Pediatrics·Surgery
Effective date
Jun 23, 2026
We identified it
Aug 14, 2026
Summary
Aetna has updated its Epilepsy Surgery policy (CPB 0394) effective 2026-06-23, clarifying medical necessity criteria for covered procedures (cerebral hemispherectomy, corpus callosotomy, temporal lobectomy, responsive cortical stimulation, stereotactic radiosurgery, and MRgLITT) and explicitly designating multiple emerging technologies as experimental/investigational. The policy requires specific patient selection criteria including failed trials of 2+ antiepileptic drugs and documented seizure severity before coverage is approved.
Action Required
By 2026-06-23: Billing team must implement prior authorization requirements for all epilepsy surgery CPT codes (61534, 61536-61538, 61541, 61543, 61566, 61736-61737, 61796-61800, 61863-61864, 61867-61868) to verify patient meets selection criteria before claim submission. Update billing system and prior auth templates to require documentation of: (1) non-epileptic attacks ruled out, (2) epilepsy diagnosis and seizure type documented, (3) failure of 2+ antiepileptic drugs for minimum 3 months each with compliance proof, and (4) seizure frequency interfering with daily living. Notify neurosurgery providers and neurologists of updated criteria. Explicitly deny or classify as investigational any claims for artificial intelligence-assisted localization, chronic pulvinar stimulation, epicranial neurostimulator, genetic variation testing, hippocampal electrical stimulation, intraoperative MRI in pediatrics, localized neocortical resection, radiofrequency-thermocoagulation, ROSA device, stem cell/gene therapy, subpial transection, high-frequency oscillations, TSPO PET imaging, or trigeminal nerve stimulation. Claims not meeting documented criteria or using experimental technologies will be denied.