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AetnaCommercial · Prior Auth · Newsletter · Oncology, Pharmacy, Dermatology +6 moreHigh impact

OfficeLink Updates - October 2025 notices and reminders (PDF)

Effective date
Not stated in the notice
Identified
Jun 19, 2026

Summary

Several precertification and coverage changes in this October 2025 notice have already taken effect. Emrelis and Zusduri require precertification as of September 1, 2025, and Zevaskyn and Imaavy require it for Medicare, with site-of-care precertification added for commercial plans. Botox, Xeomin, Procrit, Aranesp and Mircera are no longer precertified for Medicare only. Jobevne requires precertification as of October 1, 2025. Beizray (J9174) and partial excision of a posterior vertebral component (22102 and 22103) require precertification as of January 1, 2026. Effective January 1, 2026, Medicare Advantage plans in New Jersey, New York, Pennsylvania and West Virginia require EviCore pre-approval for inpatient rehabilitation, skilled nursing and listed home health codes, and Avastin, Alymsys, Mvasi, Vegzelma, Zirabev and Krystexxa are added to the commercial Site of Care for Specialty Drug Administration policy. Codes A6530 to A6534, A6539, A6545 and A6549 are non-covered compression supplies for commercial plans effective January 1, 2026. Effective November 1, 2025, CPT codes 11400-11471 and 11600-11646 are used for excision of cutaneous lesions and superficial subcutaneous lesions of cutaneous origin. Beginning December 1, 2025, CPAP devices and supplies are reimbursed only when positive airway pressure therapy is documented with adherence codes G8851, G8854 and G8855.

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What to do

Action · 14 steps
01These dates have passed, so confirm current applicability on the Availity provider portal before scheduling or billing these services.
02Precertification: submit requests at least two weeks in advance and include the actual date of service, either online through Availity or through your EMR if it is set up for electronic precertification requests.
03Submit specialty drug requests for commercial or Medicare members through Novologix, also available on Availity, and use the Search by CPT code function on the Precertification Lists page to check whether a code requires precertification.
04Medicare Advantage in New Jersey, New York, Pennsylvania and West Virginia (excluding NJ FIDE): obtain EviCore authorization before providing inpatient rehabilitation (revenue code 128), skilled nursing levels 1, 2, 3 and 4, or the listed home health HCPCS codes, because you must send authorization requests before providing services to get paid.
05If treatment started on or after January 1, 2026 and no request was submitted, contact EviCore right away.
06Request authorization online at EviCore, by calling 1-888-622-7329 during normal business hours, or by faxing the request form.
07For urgent care needing services in less than 48 hours, call EviCore for a fast review and tell the representative the request is for urgent care.
08Ordering physicians should share approval numbers with the facility performing the procedure.
09If the requested service differs from what EviCore approved, the facility must contact EviCore for review and approval before submitting claims.
10Services performed without approval may be denied, and members should not be asked for payment as outlined in your agreement.
11Commercial plans: treat compression stockings codes A6530 to A6534, A6539, A6545 and A6549 as non-covered supplies, and for Texas fully insured plans, expect implementation only where applicable regulatory requirements are met.
12Commercial plans: check the Site of Care for Specialty Drug Administration policy for Avastin, Alymsys, Mvasi, Vegzelma, Zirabev and Krystexxa.
13Excisions: use CPT 11400-11471 and 11600-11646 for excision of cutaneous lesions and superficial subcutaneous lesions of cutaneous origin.
14CPAP: document positive airway pressure therapy using adherence codes G8851, G8854 and G8855, because the device and supplies are not reimbursed without it.

Codes mentioned

J9035Q5126Q5107Q5129Q5118J2507G0151G0153G0155G0162G0299G0300G0493G0496A6530A6534A6539A6545A654911400114711160011646J3490J3590C9399J9999J0585J0588J0885J0881J0882J0887J0888J91742210222103J2506G8851G8854G8855

Original notice

OfficeLink Updates - October 2025 notices and reminders (PDF)
aetna.com · Always check the source before changing claims.
View original ↗

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Related policy hubs

Aetna policiesOncologyPharmacyDermatologyGeneral SurgerySleep MedicinePulmonologyOrthopedicsNeurosurgeryGeriatricsCode J9035Code Q5126Code Q5107Code Q5129Code Q5118Code J2507Code G0151Code G0153Code G0155Code G0162Code G0299Code G0300Code G0493Code G0496Code A6530Code A6534Code A6539Code A6545Code A6549Code 11400Code 11471Code 11600Code 11646Code J3490Code J3590Code C9399Code J9999Code J0585Code J0588Code J0885Code J0881Code J0882Code J0887Code J0888Code J9174Code 22102Code 22103Code J2506Code G8851Code G8854Code G8855

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