CommercialCoverageMedium impact
Cholecystokinin Cholescintigraphy (CPB 0266, reviewed 2026-04-16)
Aetna·Radiology, Nuclear Medicine, Gastroenterology +2 more·Medical Policy
Effective date
Apr 16, 2026
We identified it
Aug 15, 2026
Summary
Aetna has clarified its medical necessity criteria for Cholecystokinin (CCK) cholescintigraphy, establishing 8 specific covered indications and explicitly designating all other uses (including pain provocation as a predictor of post-operative symptom relief) as experimental/investigational. Billing teams must verify that claims for CPT 78226, 78227, and HCPCS J2805 include documentation supporting one of the 8 covered indications; claims without matching documentation will be denied.
Action Required
By 2026-04-16: Billing team must update claim submission logic and prior authorization requirements for CPT 78226, 78227, and HCPCS J2805 to enforce the 8 covered indications listed in the policy. Before submitting claims, verify that provider documentation explicitly references ONE of the following: (1) confirm/exclude chronic calculous cholecystitis, (2) confirm chronic acalculous cholecystitis, (3) differentiate common duct obstruction from sphincter of Oddi dysfunction, (4) exclude acute acalculous cholecystitis, (5) diagnose sphincter of Oddi dysfunction during imaging, (6) evaluate biliary symptoms with negative ultrasound/scintigraphy, (7) shorten study time from 3-4 hours to 60 minutes, or (8) empty gallbladder in fasting >24 hours. Reject or hold claims that cite pain provocation, biliary dyskinesia symptom prediction, or other non-listed indications. Add this checklist to encounter forms and billing software rules. Communicate to providers that ICD-10 codes K82.8 and Z98.890-Z98.891 are NOT covered indications. Claims submitted without qualifying documentation will be denied by Aetna.