CommercialCoverageHigh impact
Repository Corticotropin Injection (Acthar Gel and Purified Cortrophin Gel) (CPB 0762, reviewed 2025-12-08)
Aetna·Pediatrics, Neurology, Dermatology +5 more·Pharmacy
Effective date
Dec 8, 2025
We identified it
Aug 15, 2026
Summary
Aetna updated its coverage policy for Repository Corticotropin Injection (Acthar Gel and Purified Cortrophin Gel) to clarify that only Acthar Gel for infantile spasms in children under 2 years old is medically necessary and covered. All other indications—including multiple sclerosis, rheumatic disorders, collagen diseases, dermatologic diseases, allergic states, respiratory diseases, and edematous states—are now explicitly classified as not medically necessary, experimental, investigational, or unproven. Precertification is required for all uses, and billing teams must ensure claims are submitted only for the covered indication or face denials.
Action Required
Immediately effective (2025-12-08): Billing team must update all billing system rules and claim submission processes to restrict coverage of Acthar Gel (J0801) and Purified Cortrophin Gel (J0802) to infantile spasms ONLY (ICD-10 codes G40.821-G40.824) in members under 2 years of age. All other indications listed in the policy must be denied at submission. REQUIREMENTS: (1) Update billing software to block claims for J0801 and J0802 unless diagnosis code is G40.821, G40.822, G40.823, or G40.824 AND patient age is under 24 months. (2) Implement mandatory precertification workflow—all Acthar Gel and Purified Cortrophin Gel claims require precertification via (866) 752-7021 or fax (888) 267-3277 before submission. (3) Notify all providers, especially pediatrics and neurology departments, that all non-infantile-spasms indications (MS exacerbations, rheumatoid arthritis, lupus, psoriasis, sarcoidosis, etc.) will be denied. (4) Create denial reason codes in billing system specifying 'Not medically necessary per Aetna CPB 0762' for off-label uses. (5) Train billing staff and front-desk staff to verify patient age and precertification status before appointment scheduling. Failure to enforce these restrictions will result in claim denials and potential recoupment of incorrectly paid claims.