CommercialCoverageHigh impact
Nirsevimab-alip (Beyfortus) (CPB 1038, reviewed 2025-10-09)
Aetna·Pediatrics, Critical Care, Cardiothoracic Surgery +2 more·Medical Policy
Effective date
Oct 9, 2025
We identified it
Aug 16, 2026
Summary
Aetna has issued a new clinical policy (CPB 1038, effective 2025-10-09) establishing medical necessity criteria for nirsevimab-alip (Beyfortus) RSV prophylaxis in infants and children. The policy aligns with CDC ACIP recommendations and coordinates coverage with maternal RSV vaccination, specifying eligibility by age, risk factors, and prior vaccination status. Billing teams must implement prior authorization requirements and ensure claims are submitted only when documented medical necessity criteria are met.
Action Required
Effective immediately (policy dated 2025-10-09): Billing team must implement prior authorization requirements for CPT 90380, 90381, 90382, and administration codes 96380, 96381 before processing claims. Update billing system to enforce Aetna's medical necessity criteria: verify patient age (infants <8 months in first RSV season, or 8-24 months in second RSV season with risk factors), confirm absence of prior monoclonal antibody doses, and document maternal RSV vaccine status or clinical exception. Providers must document specific risk conditions (congenital heart disease, prematurity requiring oxygen, immunocompromise, etc.) in encounter notes before submission. Front desk staff should screen for maternal vaccination dates at check-in. Claims submitted without documented medical necessity or prior auth will be denied. Update encounter forms and EMR templates to capture all required clinical criteria. Coordinate with pediatric, neonatal intensive care, and cardiothoracic surgery departments to ensure providers understand the policy's conditional approval for post-operative dosing.