CommercialCoverageMedium impact
ADAMTS13 Assay for Thrombotic Thrombocytopenic Purpura (TTP) (CPB 0780, reviewed 2026-10-27)
Aetna·Hematology, Critical Care, Nephrology +2 more·Medical Policy
We identified it
Oct 28, 2026
Summary
Aetna's ADAMTS13 Assay policy (CPB 0780) was reviewed on 2026-10-27 and establishes medical necessity criteria for ADAMTS13 testing limited to two indications: assessing prognosis in TTP and distinguishing HSCT-TMA from TTP. All other uses remain classified as experimental/investigational and are not covered. Billing teams must verify that claims for ADAMTS13 (CPT 85397) meet one of the two covered indications or face denial.
Action Required
Verify current applicability: This policy was last reviewed 2026-10-27 but no explicit effective date is stated in the source. Billing team should confirm with Aetna whether this represents a recent change or a routine review. Once confirmed current, implement the following: (1) Restrict ADAMTS13 (CPT 85397) claim submission to only these two indications: prognosis assessment in TTP or HSCT-TMA/TA-TMA differentiation from TTP. (2) Deny or return to providers any claims for ADAMTS13 tied to the extensive experimental/investigational indications listed (e.g., COVID-19 biomarker, HCC detection, diabetic retinopathy, cerebral infarction prediction). (3) Update billing software and provider education materials to reflect that ADAMTS13 mutation testing and vWF antigen-to-ADAMTS13 activity ratios are also non-covered. (4) Code selection: Use ICD-10 codes M31.11 (HSCT-TMA) or M31.10/M31.19 (other TMA) to support medical necessity; do not submit claims with the non-covered diagnosis codes listed in the policy. (5) Obtain prior authorization or medical record documentation from providers confirming the clinical indication falls within the two covered scenarios before processing claims.