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AetnaAll Plans · Coverage · Medical Policy · Gastroenterology, General Surgery, Bariatric SurgeryMedium impact

Barrett's Esophagus (CPB 0728, reviewed 2026-10-26)

Effective date
Not stated in the notice
Identified
Oct 31, 2026

Summary

Aetna's Clinical Policy Bulletin 0728 on Barrett's esophagus (reviewed 2026-10-26) considers radiofrequency ablation medically necessary for members with low-grade dysplasia confirmed by histology from 2 or more endoscopies 3 or more months apart. For members with high-grade dysplasia by biopsy, it considers endoscopic mucosal resection, esophagectomy, fundoplication, photodynamic therapy and radiofrequency ablation medically necessary, and it considers argon plasma coagulation, cryotherapy, laser therapy and several other listed interventions and tests experimental, investigational, or unproven because their effectiveness has not been established.

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What to do

Action · 4 steps
01Billing team: Before billing radiofrequency ablation for Barrett's esophagus with low-grade dysplasia, confirm the record shows histological confirmation of low-grade dysplasia by 2 or more endoscopies 3 or more months apart, because that is the medical necessity criterion the policy states.
02For high-grade dysplasia by biopsy, the policy lists endoscopic mucosal resection, esophagectomy, fundoplication, photodynamic therapy and radiofrequency ablation as medically necessary.
03Do not bill argon plasma coagulation, cryotherapy, laser therapy, multi-polar electro-coagulation or ultrasonic therapy for Barrett's esophagus, since the policy considers them experimental, investigational, or unproven for that use.
04The source gives a review date of 2026-10-26 and no effective date, so confirm current applicability at https://www.aetna.com/cpb/medical/data/700_799/0728.html.

Codes mentioned

431004310143107431084311243113431164311743118431214312243123431244321143217432294325443270432794328043286432874328843325433274332843338965709657143206432524362043621436224363143632436334363443644436458122881229812778836488365883669111091111J9600K22.710K22.711K22.719K22.70

Original notice

Barrett's Esophagus (CPB 0728, reviewed 2026-10-26)
aetna.com · Always check the source before changing claims.
View original ↗

Related changes

See all Aetna changes →
Barrett's Esophagus (CPB 0728, reviewed 2025-11-25)MediumNo effective date · Medical PolicyDostarlimab-gxly (Jemperli) (CPB 0993, reviewed 2026-01-27)MediumNo effective date · Medical PolicyGastroesophageal Reflux Disease (GERD) (CPB 0213, reviewed 2026-07-21)MediumNo effective date · Medical PolicyPhotodynamic Therapy (CPB 0375, reviewed 2026-05-21)MediumNo effective date · Medical PolicyBrowse every Aetna change in the policy list

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Aetna policiesGastroenterologyGeneral SurgeryBariatric SurgeryCode 43100Code 43101Code 43107Code 43108Code 43112Code 43113Code 43116Code 43117Code 43118Code 43121Code 43122Code 43123Code 43124Code 43211Code 43217Code 43229Code 43254Code 43270Code 43279Code 43280Code 43286Code 43287Code 43288Code 43325Code 43327Code 43328Code 43338Code 96570Code 96571Code 43206Code 43252Code 43620Code 43621Code 43622Code 43631Code 43632Code 43633Code 43634Code 43644Code 43645Code 81228Code 81229Code 81277Code 88364Code 88365Code 88366Code 91110Code 91111Code J9600Code K22.710Code K22.711Code K22.719Code K22.70

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