AetnaCommercial · Coverage · Medical Policy · Orthopedics, ENT (Ear, Nose & Throat), Dentistry +2 moreMedium impact
Bone and Tendon Graft Substitutes and Adjuncts (CPB 0411, reviewed 2026-08-18)
Effective date
Not stated in the notice
Identified
Oct 1, 2026
Summary
Aetna considers INFUSE Bone Graft (bone morphogenetic protein-2) medically necessary for lumbar spinal fusion in skeletally mature persons who meet CPB 0743 criteria, when implanted by an ALIF or lateral (OLIF, DLIF, XLIF or LLIF) approach or with 1 or 2 level TLIF procedures, and for acute open tibial shaft fractures stabilized with intramedullary nail fixation when applied within 14 days after the initial fracture. Cadaveric allograft and demineralized bone matrix are medically necessary for spinal fusions and for filling osteochondral defects, and PMMA or calcium sulfate antibiotic beads are medically necessary with intravenous antibiotics for chronic osteomyelitis. Aetna considers INFUSE for ankle and cervical fusions, platelet-rich plasma, and mesenchymal stem cell therapy for orthopedic applications experimental, investigational or unproven.
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01Billing team: bill INFUSE Bone Graft as covered only for lumbar spinal fusion that meets CPB 0743 criteria and is implanted by an ALIF or lateral approach or with 1 or 2 level TLIF procedures, or for an acute open tibial shaft fracture treated within 14 days after the initial fracture.
02Do not bill INFUSE for ankle fusion, cervical fusion, 3 or more level TLIF, or posterior or postero-lateral lumbar fusion, which the policy treats as experimental, investigational or unproven.
03Bill PMMA or calcium sulfate antibiotic beads only when they are used with intravenous antibiotics for chronic osteomyelitis, and bill bone marrow injections only for unicameral or simple bone cysts.
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