CommercialCoverageHigh impact
Complex Regional Pain Syndrome (CRPS): Diagnosis (CPB 0147, reviewed 2026-03-30)
Aetna·Pain Management, Neurology, Orthopedics +1 more·Medical Policy
Effective date
Mar 30, 2026
We identified it
Aug 15, 2026
Summary
Aetna has updated its CRPS diagnosis policy (CPB 0147) to clarify that numerous advanced diagnostic tests and procedures are NOT covered due to insufficient scientific evidence. This includes imaging (MRI, CT, PET), biomarker testing, genetic profiling, phentolamine testing, and specialized techniques like thermography and laser Doppler flowmetry. The policy emphasizes that CRPS diagnosis is clinical based on Budapest Criteria, not test-based.
Action Required
By March 30, 2026: Billing team must update claims processing system to deny or require prior authorization review for all CRPS diagnostic testing codes listed in this policy. Specifically: (1) Flag claims for MRI/MRS (CPT 73218-73723, 76390), CT (77078), PET (78811-78813), ultrasound (76881-76882), and vascular studies (93922-93931) when billed with ICD-10 G90.50-G90.9 or M85.80-M85.9; (2) Implement automatic denial for intravenous phentolamine (J2760) for CRPS diagnosis; (3) Deny or require prior authorization for all genetic/biomarker testing (CPT 81111, 81370-81383, 82725-82726, 82978) when linked to CRPS; (4) Update encounter templates and provider education materials to clarify that CRPS diagnosis relies on clinical Budapest Criteria, not diagnostic testing. Add a compliance note in the system to alert coders that these procedures are considered experimental/unproven for CRPS. Failure to implement will result in claim denials and potential compliance issues. Contact Aetna for any appeals or prior authorization requests for medically necessary exceptions.