CommercialPrior AuthHigh impact
Cardiopulmonary Exercise Testing (CPB 0825, reviewed 2025-12-03)
Aetna·Cardiology, Pulmonology, Internal Medicine +1 more·Medical Policy
Effective date
Dec 3, 2025
We identified it
Aug 15, 2026
Summary
Aetna has updated its Cardiopulmonary Exercise Testing (CPET) policy (CPB 0825, effective 2025-12-03) to define medical necessity criteria and clarify covered versus experimental indications. CPT 94621 is covered only when specific clinical conditions are met (e.g., post-thromboendarterectomy evaluation, exercise prescription for cardiac/pulmonary rehabilitation, CHF transplant evaluation, congenital heart disease assessment, Long COVID evaluation). CPET is classified as experimental for numerous conditions including first-line diagnostics, routine pre-operative assessment, cystic fibrosis, and dystrophinopathies. Billing teams must implement prior authorization checks and ensure claims include qualifying diagnoses.
Action Required
By 2025-12-03, billing team must: (1) Update billing software to require prior authorization for CPT 94621 (Cardiopulmonary exercise testing) when billed with non-covered ICD-10 diagnoses; (2) Create a validation rule that CPT 94621 claims MUST include one of the covered indications (e.g., I27.24, I50.1-I50.9, U09.9, congenital heart disease codes, or post-COVID diagnosis); (3) Reject or flag claims with experimental indications (e.g., D57.00-D57.819 sickle cell, E84.0-E84.9 cystic fibrosis, E66.01-E66.9 obesity, G71.01 muscular dystrophy, G35.A-G35.D multiple sclerosis, J45.20-J45.998 asthma, M30.3 Kawasaki disease, Q87.40-Q87.43 Marfan syndrome, or routine pre-operative screening); (4) Providers and medical staff must document the specific clinical indication on the order; (5) Update encounter templates and order sets to prompt providers to select qualifying diagnosis. Failure to obtain prior auth or bill with non-covered diagnoses will result in claim denials.