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Drug-Eluting Stents (CPB 0621, reviewed 2026-09-23)
Aetna·Cardiology, Vascular Surgery, Radiology +3 more·Pharmacy
We identified it
Oct 1, 2026
Summary
This is a comprehensive Aetna clinical policy bulletin on drug-eluting stents (CPB 0621) reviewed on September 23, 2026. The policy defines covered indications for FDA-approved drug-eluting stents (everolimus, paclitaxel, sirolimus, zotarolimus, and ridaforolimus-eluting) for coronary and peripheral arterial disease, while classifying biodegradable polymer stents, antibody-coated stents, and drug-eluting stents for non-standard indications as experimental/investigational. Billing teams must ensure claims align with specific medical necessity criteria for stenosis thresholds and patient conditions.
Action Required
Immediately: Billing team must audit current stent claims (CPT 92928-92945, 37236-37239, HCPCS C1874-C1875, C9600-C9607) against this policy. (1) Verify that only FDA-approved everolimus, paclitaxel, sirolimus, zotarolimus, or ridaforolimus-eluting stents are billed for Aetna members; (2) Ensure provider documentation supports medical necessity: coronary stenosis ≥50% in left main artery, OR refractory angina with ≥70% stenosis in one or more coronaries, OR stenosis >50% with FFR ≤0.80; (3) Flag and deny claims for biodegradable polymer stents (C1874, C1875), antibody-coated stents, drug-eluting ureteral stents (C2617, C2625), and stents for unlisted indications (intracranial atherosclerosis CPT 61635, peripheral vascular disease outside approved Eluvia/Zilver PTX indications) as experimental/investigational; (4) Update billing software logic to automatically route stent procedures through prior authorization workflow when indications are unclear or fall outside medical necessity criteria. Routes non-compliant claims to denial queue with reference to CPB 0621. Failure to implement will result in claim denials and potential member appeals.