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Aducanumab-avwa (Aduhelm) (CPB 0996, reviewed 2025-12-09)
Effective date
Not stated in the notice
Identified
Aug 17, 2026
Summary
Aetna considers aducanumab-avwa (Aduhelm) medically necessary for treatment of Alzheimer's disease for commercial medical plans when the initial approval criteria are met, and considers all other indications experimental, investigational or unproven. Aduhelm requires precertification, and Aduhelm was discontinued in November 2024.
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What to do
Action · 9 steps
01Billing team: Precertification of Aduhelm is required of all Aetna participating providers and members in applicable plan designs.
02Call (866) 752-7021 or fax (866) 267-3277; Statement of Medical Necessity precertification forms are under Specialty Pharmacy Precertification.
03The Site of Care Utilization Management Policy applies to Aduhelm infusions.
04The medication must be prescribed by or in consultation with a geriatrician, neurologist, psychiatrist, or neuropsychiatrist.
05Initial approval requires all of the following in the member record: age 50 or older, or if under 50, an APP, PSEN1 or PSEN2 genetic mutation or other clinical documentation supporting early onset AD; mild cognitive impairment due to AD or mild AD dementia; objective cognitive impairment at baseline; a baseline CDR-Global score of 0.5 or 1, MMSE score of 21 to 30, or MoCA score of 16 or greater; amyloid pathology confirmed by PET scan or by CSF lumbar puncture results; a brain MRI within one year before initiating treatment; and either ApoE e4 genotype testing performed before treatment, or documentation that the prescriber informed the member it cannot be determined whether they are ApoE e4 homozygous.
06The member must be enrolled in a randomized controlled trial under an IND application or an NIH-supported trial.
07Reauthorization at 6 months requires ARIA evaluation on MRI before the 5th and 7th doses, and reauthorization at 12 months requires ARIA evaluation on MRI before the 9th and 12th doses.
08Coverage will not be provided for members with a suspected neurodegenerative etiology of cognitive impairment other than AD, a requirement for therapeutic anticoagulation (except aspirin at a prophylaxis dose of 325 mg or less daily), TIA, stroke or seizures within the past 12 months, or a bleeding disorder not under adequate control (platelet count below 50,000 or INR above 1.5).
09Aduhelm is not used in combination with other amyloid beta-directed antibodies, such as donanemab-azbt or lecanemab.
Codes mentioned
622707055170552705537860878811788148140181405814069636596368J0172A9586A9598J0174J0175Q9982S3852G30.0G30.9G31.84D69.0D69.9G23.0G23.9G31.01G31.9G32.0G32.89R79.1Z79.01Z79.02Z86.69Z86.73
Original notice
Aducanumab-avwa (Aduhelm) (CPB 0996, reviewed 2025-12-09)
aetna.com · Always check the source before changing claims.
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Aetna policiesGeriatricsNeurologyPsychiatryCode 62270Code 70551Code 70552Code 70553Code 78608Code 78811Code 78814Code 81401Code 81405Code 81406Code 96365Code 96368Code J0172Code A9586Code A9598Code J0174Code J0175Code Q9982Code S3852Code G30.0Code G30.9Code G31.84Code D69.0Code D69.9Code G23.0Code G23.9Code G31.01Code G31.9Code G32.0Code G32.89Code R79.1Code Z79.01Code Z79.02Code Z86.69Code Z86.73