CommercialCoverageHigh impact
High Intensity Focused Ultrasound (CPB 0766, reviewed 2025-11-13)
Aetna·Urology, Radiation Oncology, OB-GYN +4 more·Radiology
Effective date
Nov 13, 2025
We identified it
Aug 17, 2026
Summary
Aetna's updated HIFU policy (CPB 0766, effective immediately) narrows coverage to ONLY radio-recurrent prostate cancer while designating HIFU as experimental/investigational for 50+ other indications including primary prostate cancer, benign prostatic hypertrophy, breast cancer, and multiple CNS/gynecological conditions. Billing teams must immediately deny or require prior authorization for non-covered HIFU procedures and update claim scrubbing rules to flag ineligible diagnosis codes.
Action Required
IMMEDIATE (effective 2025-11-13): Billing team must implement the following: (1) Update billing system claim scrubbing rules to ONLY allow CPT 55880 when paired with ICD-10 C61 diagnosis code AND documented as radio-recurrent prostate cancer (not primary treatment); (2) Flag or auto-deny all claims for CPT codes 0950T, 61715, and C9734 as non-covered/experimental for ALL diagnoses listed in policy; (3) Create claim edit in billing software to reject CPT 0632T and 0793T submissions for pulmonary artery denervation; (4) Update prior authorization workflow to REQUIRE prior auth denial letter from Aetna BEFORE billing for any HIFU procedures outside the covered indication; (5) Notify urology, radiation oncology, and OB-GYN providers of coverage restrictions via email with specific examples (e.g., HIFU for benign prostatic hypertrophy, primary prostate cancer, and uterine fibroids are NOT covered); (6) Audit recent HIFU claims (past 30 days) for non-covered diagnoses and prepare rebilling strategy or refund processing. Failure to implement these edits will result in claim denials and payment clawbacks from Aetna.