CommercialCoverageHigh impact
Nesiritide (Natrecor) (CPB 0709, reviewed 2025-11-24)
Aetna·Cardiology, Critical Care, Internal Medicine +1 more·Medical Policy
Effective date
Nov 24, 2025
We identified it
Aug 16, 2026
Summary
Aetna's updated nesiritide (Natrecor) policy (CPB 0709, effective 2025-11-24) narrows coverage to ONLY acute management of acutely decompensated CHF with dyspnea at rest or minimal activity via IV infusion. All other uses—including intermittent infusions, repetitive outpatient use, renal enhancement, prophylactic use, and subcutaneous administration—are now classified as experimental/investigational and not covered. Billing teams must immediately deny or reject claims for non-covered indications.
Action Required
By 2025-11-24, billing team must: (1) Update billing system to ONLY allow nesiritide claims (J2325 with IV infusion CPT codes 96365-96368) when linked to ICD-10 codes I50.21, I50.23, I50.31, I50.33, I50.41, or I50.43 (acute/acute-on-chronic CHF with dyspnea). (2) Configure system to AUTOMATICALLY DENY all nesiritide claims with ICD-10 codes I50.1, I50.20, I50.22, I50.30, I50.32, I50.40, I50.42, I50.810-I50.9, and all renal codes (N00.0-N29). (3) BLOCK CPT 96372 (subcutaneous injection) entirely for nesiritide—this route is now unproven. (4) Reject any claims for repetitive weekly infusions, outpatient 'tune-up' protocols, or prophylactic use with denial reason 'Experimental/investigational per CPB 0709.' (5) Alert providers and coders to stop billing nesiritide for renal protection, diuresis enhancement, or cardiac surgery adjuvant use. Failure to implement these restrictions will result in improper claim payment and audit risk.