Therapeutic Drug Monitoring of Anti-Tumor Necrosis Factor Blocking Agents (CPB 1091, reviewed 2026-10-16)

Billing team must verify current applicability of this policy and implement controls to ensure claims for anti-TNF therapeutic drug monitoring are only submitted when: (1) patient has confirmed IBD diagnosis (ICD-10 K50 or K51), AND (2) documentation supports either loss of response to the agent OR patient is ≤21 years old. Deny or route for manual review claims using CPT 0514U, 0515U, 80145, or 80230 for non-IBD indications (psoriasis, rheumatoid arthritis, spondyloarthritis, uveitis coded with L40, M05-M08, M45) or experimental tests (anti-histone antibodies, DNA/mRNA biomarkers). Coordinate with providers to obtain prior authorization documentation of loss of response before processing monitoring claims. Confirm whether Aetna has established an effective date for enforcement of these criteria beyond the 2026-10-16 review date, as the policy source does not state a specific implementation deadline.