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AetnaCommercial · Prior Auth · Medical Policy · Allergy & ImmunologyMedium impact

Hereditary Angioedema (CPB 0782, reviewed 2025-11-13)

Effective date
Not stated in the notice
Identified
Aug 15, 2026

Summary

Aetna Clinical Policy Bulletin 0782 covers hereditary angioedema (HAE) agents for commercial medical plans. Precertification of HAE agents is required of all Aetna participating providers and members in applicable plan designs. Aetna considers prophylactic HAE agents medically necessary when the drug is prescribed by or in consultation with a prescriber who specializes in HAE management, is not used in combination with other HAE prophylaxis, and the member meets the C1 inhibitor criteria at diagnosis with other causes of angioedema ruled out. Berinert is considered medically necessary for acute attacks only for members with a contraindication, intolerance or ineffective response to Ruconest after a one-month trial. Continuation of prophylaxis requires a significant reduction in attack frequency (for example, at least 50 percent) and reduced use of medications for acute attacks.

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What to do

Action · 7 steps
01Billing team and providers: Obtain precertification for HAE agents, which the source says is required of participating providers and members in applicable plan designs.
02Call (866) 752-7021 or fax (888) 267-3277, and use the Statement of Medical Necessity forms on the Specialty Pharmacy Precertification page.
03Confirm the chart documents C1 inhibitor deficiency confirmed by laboratory testing, or normal C1 inhibitor with a pathogenic variant or with angioedema refractory to a one-month trial of high-dose antihistamine, and that other causes of angioedema were ruled out.
04Confirm the prescriber specializes in HAE management and that the drug is not used with other HAE prophylaxis.
05For Berinert used for acute attacks, document a contraindication, intolerance or ineffective response to Ruconest after a one-month trial.
06For Cinryze, the Site of Care Utilization Management Policy applies.
07For continuation requests, document the significant reduction in attack frequency and the reduced use of acute-attack medications.

Codes mentioned

861608616196372963749637996401J0593J0596J0597J0598J1290D84.1E88.09

Original notice

Hereditary Angioedema (CPB 0782, reviewed 2025-11-13)
aetna.com · Always check the source before changing claims.
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Related policy hubs

Aetna policiesAllergy & ImmunologyCode 86160Code 86161Code 96372Code 96374Code 96379Code 96401Code J0593Code J0596Code J0597Code J0598Code J1290Code D84.1Code E88.09

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