CommercialCoverageHigh impact
Liver and Other Neoplasms - Treatment Approaches (CPB 0268, reviewed 2026-04-16)
Aetna·Oncology, Radiation Oncology, General Surgery +2 more·Medical Policy
Effective date
Apr 16, 2026
We identified it
Aug 17, 2026
Summary
Aetna has updated Clinical Policy Bulletin 0268 (replacing CPB 338) to clarify medical necessity coverage for liver and neoplasm treatment approaches including percutaneous ethanol injection, chemoembolization, intra-hepatic chemotherapy, and intra-hepatic microspheres. The policy specifies covered indications, excludes certain experimental approaches, and identifies specific CPT/HCPCS codes with coverage restrictions for various tumor types and delivery methods.
Action Required
By 2026-04-16: Billing team must immediately review and update billing system rules to enforce Aetna coverage criteria for liver neoplasm treatment codes. Specifically: (1) Configure system to require prior authorization documentation for CPT 37243, 96420, 96422, 96423, 96425 (chemoembolization and intra-arterial chemotherapy procedures); (2) Create coverage edits to deny claims for non-covered indications including: CPT 96420/96422/96423/96425 for breast cancer liver metastases, CPT 37243 for degradable starch microspheres, HCPCS C1982/C8004/C9797 (TriNav system), and E0767 (TheraBionic system); (3) Flag all claims for intra-hepatic microspheres (C2616, S2095, Q3001) with colorectal cancer, esophageal cancer, gallbladder cancer, or uveal melanoma metastases as requiring medical necessity documentation; (4) Require documentation of ECOG performance status ≤2 and serum bilirubin <2 mg/dL for cholangiocarcinoma cases using intra-hepatic microspheres; (5) Update encounter templates and prior authorization request forms to identify patient diagnosis, treatment indication, and failed systemic therapies when applicable. Billing team must train all staff on experimental/non-covered procedures listed in policy. Claims submitted without proper authorization or for non-covered indications will be denied by Aetna effective the policy date.