CommercialCoverageMedium impact
Afamelanotide (Scenesse) (CPB 0962, reviewed 2025-12-09)
Aetna·Dermatology, Hematology, Internal Medicine·Medical Policy
Effective date
Dec 9, 2025
We identified it
Aug 17, 2026
Summary
Aetna has issued a new medical policy (CPB 0962, effective 2025-12-09) establishing coverage criteria for afamelanotide (Scenesse) implants. The drug is covered ONLY for biochemically confirmed erythropoietic protoporphyria (EPP) in adults with elevated protoporphyrin levels in red blood cells; all other indications are considered experimental/investigational. Billing teams must ensure prior authorization is obtained and claims are only submitted for the approved indication with proper ICD-10 coding.
Action Required
By December 9, 2025: (1) Billing team must update billing system to require prior authorization for HCPCS code J7352 (afamelanotide implant) for Aetna commercial plans. (2) Configure system to ALLOW claims ONLY when ICD-10 diagnosis code E80.0 (hereditary erythropoietic porphyria) is present AND prior authorization is approved. (3) DENY or flag all claims with ICD-10 codes A49.02 (MRSA) or I63.9 (cerebral infarction) paired with J7352, as these indications are not covered. (4) Providers must document biochemically confirmed EPP diagnosis with protoporphyrin levels above lab reference range in red blood cells prior to submission. (5) Update encounter forms and pre-authorization templates to require evidence of elevated protoporphyrin lab values. (6) Train billing and clinical staff that only adult patients with confirmed EPP qualify; all other uses are experimental. Failure to obtain prior authorization or submit with non-covered indications will result in claim denials.