CommercialPrior AuthMedium impact
Pancreas Transplantation Alone (PTA) and Islet Cell Transplantation (CPB 0601, reviewed 2026-09-18)
Aetna·Transplant Surgery, Endocrinology, Internal Medicine·Medical Policy
We identified it
Sep 30, 2026
Summary
Aetna updated its clinical policy for Pancreas Transplantation Alone (PTA) and Islet Cell Transplantation (CPB 0601), reviewed 2026-09-18. This policy establishes medical necessity criteria, precertification requirements for Lantidra suspension, covered CPT codes (0584T, 0585T, 0586T, 48160, 48550-48552, 48554, 48556), and defines absolute/relative contraindications. Billing teams must implement precertification workflows and ensure compliance with the detailed selection criteria for coverage.
Action Required
By 2026-09-18, billing and prior authorization teams must: (1) Update authorization workflows to require MANDATORY precertification for donislecel-jujn (Lantidra) suspension through National Medical Excellence (NME) at 877-212-8811 for all Aetna participating providers and members in applicable plan designs; (2) Configure billing system to flag CPT codes 0584T, 0585T, 0586T, 48160, 48550-48552, 48554, and 48556 for prior auth review; (3) Create checklist documenting verification of all medical necessity criteria (general criteria, disease-specific criteria, and absence of absolute contraindications) before claim submission; (4) Train providers on relative contraindication exceptions requiring supporting documentation within 4 weeks demonstrating 3 months stability for substance abuse/psychiatric issues; (5) Implement tracking to ensure Lantidra infusions do not exceed maximum of 3 infusions per member. Failure to obtain precertification will result in claim denials.