CommercialPrior AuthMedium impact
Venous Stenting for the Treatment of Idiopathic Intracranial Hypertension (CPB 1039, reviewed 2026-01-14)
Aetna·Neurosurgery, Neurology, Ophthalmology +2 more·Medical Policy
Effective date
Jan 14, 2026
We identified it
Aug 18, 2026
Summary
Aetna has updated its medical policy (CPB 1039) to establish coverage criteria for venous stenting in the transverse sinus for treatment of medically refractory idiopathic intracranial hypertension (IIH). The policy specifies 10 strict medical necessity criteria that must be met for coverage of CPT 61635, and explicitly excludes intravascular ultrasound (CPT 37252, 37253) as experimental. Billing teams must implement prior authorization requirements and ensure all documentation criteria are present before claim submission.
Action Required
IMMEDIATELY (Policy effective 2026-01-14): (1) Billing Team: Implement prior authorization requirement in billing system for CPT 61635 (venous stent placement). (2) Coding Team: Add hard-stop rule to reject claims for CPT 37252 and 37252 (intravascular ultrasound) when billed with ICD-10 G93.2 - these are non-covered as experimental. (3) Prior Auth Team: Create authorization checklist requiring documentation of all 10 medical necessity criteria before approving CPT 61635: ophthalmologic exam with vision loss/papilledema; normal neurologic exam (except vision/CN VI); neuroimaging exclusions; LP with ICP ≥25 cm H2O within 3 months; normal CSF analysis; normal CBC/electrolytes/PT/PTT; BP <150 mmHg; exclusion of obstructive sleep apnea/SLE/vasculitis/lead poisoning/neurosarcoidosis; MRV showing bilateral transverse sinus stenosis or unilateral stenosis with contralateral hypoplasia; documented failure of maximal medical management and CSF shunting; pressure gradient >8 mmHg across stenosis (to be documented at time of venography). (4) Provider Education: Notify all neurosurgery and interventional radiology providers of coverage criteria and need for comprehensive documentation. (5) Claims Processing: Flag any claims for CPT 61635 lacking complete documentation of all criteria for denial with specific reference to CPB 1039 requirements. Failure to obtain prior authorization or submit complete documentation will result in claim denials.