CommercialCoverageHigh impact
Nutritional Support (CPB 0061, reviewed 2026-01-15)
Aetna·Critical Care, Gastroenterology, General Surgery +7 more·Medical Policy
Effective date
Jan 15, 2026
We identified it
Aug 18, 2026
Summary
Aetna Clinical Policy Bulletin 0061 (effective 2026-01-15) replaces CPB 144 and establishes coverage criteria for nutritional support. Key change: coverage is limited to enteral (tube) and parenteral (IV) nutrition only—oral nutritional supplements are NOT covered unless mandated by state law. Regular food products, including high-protein powders, gluten-free foods, and weight-loss formulas, are explicitly excluded as non-medical items regardless of route. Billing teams must verify route of administration and ensure prior authorization documentation meets strict medical necessity criteria before submitting claims.
Action Required
By 2026-01-15, Billing Team must: (1) Update billing system to REJECT or flag claims for oral nutritional supplements (e.g., Ensure, Sustacal taken by mouth) as non-covered unless member's state plan mandates coverage—do NOT bill Aetna for these items; (2) Ensure all enteral/parenteral nutrition claims include medical necessity documentation proving GI tract non-function or malabsorption disease lasting >90 days, weight loss >10% in 3 months OR albumin <3.4 g/dL, and failure of oral/tube feeding (for TPN); (3) Add pre-authorization requirement to encounter forms for all tube-feeding and TPN requests with mandatory fields for: route of administration (nasogastric vs. gastrostomy vs. central line), duration (permanent impairment >90 days), supporting lab values, and justification for formula type; (4) Train front desk and clinical staff that oral formulas and food items (including gluten-free, low-carb, high-protein products) are NOT billable medical items; (5) Update denial appeals procedures to reference this policy when rejecting oral supplement claims. Failure to comply will result in claim denials and potential recoupment of already-paid oral nutrition claims.