CommercialCoverageMedium impact
Selected Techniques for Delivery of Drugs to the Brain (CPB 0731, reviewed 2025-11-26)
Aetna·Neurosurgery, Oncology, Neurology·Pharmacy
Effective date
Nov 26, 2025
We identified it
Aug 16, 2026
Summary
Aetna has reaffirmed that convection-enhanced delivery (CED) of drugs to the brain and MR-guided focused ultrasound (MRgFUS) for blood-brain barrier disruption remain experimental, investigational, or unproven. CPT code 0947T and multiple ICD-10 codes for brain tumors, Alzheimer's disease, epilepsy, and seizures are not covered under this policy. Billing teams must ensure claims for these procedures are denied or require prior authorization documentation of medical necessity.
Action Required
By 2025-12-26, Billing team must: (1) Update billing system to flag and deny all claims with CPT code 0947T as non-covered experimental procedure; (2) Add edits to prevent billing of 0947T with any of the listed ICD-10 codes (brain malignancies C71.0-C71.9, Alzheimer's disease G30.0-G30.9, epilepsy/seizures G40.001-G40.909, post-traumatic seizures R56.1, unspecified convulsions R56.9); (3) Implement prior authorization requirement for any provider submitting these codes—claims must include documentation of medical necessity and IRB approval status; (4) Notify neurosurgery and oncology departments that CED and MRgFUS procedures for brain drug delivery are not covered by Aetna; (5) Update patient education materials to reflect non-coverage. Failure to implement denials will result in claim rejections and potential compliance issues with Aetna's coverage policies.