CommercialCoverageMedium impact
Liver and Other Neoplasms - Treatment Approaches (CPB 0268, reviewed 2026-09-18)
Aetna·Oncology, Radiation Oncology, Gastroenterology +1 more·Medical Policy
We identified it
Oct 3, 2026
Summary
Aetna updated CPB 0268 (replacing CPB 338) to clarify medical necessity criteria for liver and neoplasm treatments including percutaneous ethanol injection, chemoembolization, intra-hepatic chemotherapy, and intra-hepatic microspheres. The policy establishes specific covered indications for hepatocellular carcinoma, neuroendocrine tumors, colorectal cancer metastases, and uveal melanoma, while designating numerous other applications as experimental/investigational.
Action Required
Immediately: Billing team must update claims review and prior authorization protocols to align with CPB 0268 coverage criteria. (1) For covered procedures (CPT 36245, 36260, 37242, 37243, 75894, 77750, 77778, 96446, 96420-96425, 96522, HCPCS C2616, Q3001, S2095, G0577): require medical necessity documentation confirming diagnosis is hepatocellular carcinoma without extra-hepatic spread, neuroendocrine cancer with liver involvement, colorectal cancer liver metastases, uveal melanoma liver metastases, or cholangiocarcinoma (with ECOG ≤2 and bilirubin <2 mg/dL). For carcinoid tumors, verify prior octreotide therapy failure. (2) For non-covered procedures (CPT 96420-96425 for breast cancer metastases; HCPCS C1982, C8004, C9797 for TriNav Infusion System; E0767 for TheraBionic P1; DSM-TACE applications; drug-eluting beads TACE for leiomyosarcoma/colorectal metastases; electro-chemotherapy; immunotherapy with dendritic cells; intra-hepatic chemotherapy for non-colorectal primaries): implement automated denial rules in billing system with specific denial reason codes referencing experimental/investigational status. (3) Providers must update order entry templates to flag experimental indications before submission. (4) Update denial letter templates with specific coverage criteria. Failure to implement will result in inappropriate claim approvals and potential recovery actions.