CommercialCoverageMedium impact
ADAMTS13 Assay for Thrombotic Thrombocytopenic Purpura (TTP) (CPB 0780, reviewed 2026-04-27)
Aetna·Hematology, Critical Care, Internal Medicine +2 more·Medical Policy
Effective date
Apr 27, 2026
We identified it
Aug 17, 2026
Summary
Aetna's updated ADAMTS13 Assay policy (CPB 0780, effective 2026-04-27) establishes coverage criteria for this test limited to two specific indications: assessing prognosis in TTP patients and distinguishing HSCT-TMA from TTP. All other uses are classified as experimental/investigational and will not be covered. Billing teams must immediately implement prior authorization requirements and deny claims for non-approved indications.
Action Required
By April 27, 2026: Billing team must update claim submission system to enforce coverage limitations for CPT 85397 (ADAMTS13 assay). Implement automated denial logic: DENY claims for CPT 85397 unless paired with ICD-10 codes M31.10, M31.11, or M31.19 AND clinical documentation supports either (1) prognosis assessment in confirmed TTP or (2) HSCT-TMA vs. TTP differentiation. All other indications (COVID-19 biomarker, hepatocellular carcinoma, diabetic retinopathy, sepsis-associated TMA, etc.) require automatic denial with reason code citing experimental/investigational status. Update Prior Authorization workflow to require medical necessity documentation before claim processing. Providers must document which specific TTP indication applies on all orders. Notify providers in writing of new restrictions immediately; failure to enforce will result in Aetna claim denials and potential recoupment of improper payments.