TL;DR: Aetna modified CPB 0032 covering pulmonary rehabilitation, effective March 7, 2026. Billing teams must confirm all seven medical necessity criteria before submitting CPT 94625 or 94626.
Aetna updated its pulmonary rehabilitation coverage policy under CPB 0032 on March 7, 2026. The policy governs outpatient pulmonary rehab billed under CPT 94625 and 94626, and it sets out a strict, all-criteria-must-be-met framework for medical necessity. If your practice bills pulmonary rehab for Aetna members, this is the policy your claims live or die by.
Quick-Reference: Aetna CPB 0032 Pulmonary Rehabilitation 2026
| Field | Detail |
|---|---|
| Payer | Aetna |
| Policy | Pulmonary Rehabilitation — CPB 0032 |
| Policy Code | CPB 0032 |
| Change Type | Modified |
| Effective Date | March 7, 2026 |
| Impact Level | High |
| Specialties Affected | Pulmonology, Respiratory Therapy, Thoracic Surgery, Physical Medicine & Rehabilitation, Lung Transplant Programs |
| Key Action | Audit active pulmonary rehab authorizations against all seven medical necessity criteria before March 7, 2026 |
Aetna Pulmonary Rehabilitation Coverage Criteria and Medical Necessity Requirements 2026
This is where most claim denials originate. Aetna's coverage policy for outpatient pulmonary rehab uses an "all of the following" structure. Every single criterion must be met. Miss one, and the authorization fails.
Here is what Aetna requires for CPT 94625 and 94626 to be considered medically necessary:
1. Qualifying diagnosis. The member must have a chronic pulmonary disease or a condition that affects pulmonary function. Aetna's list is long and specific: alpha-1 antitrypsin deficiency, asbestosis, asthma, emphysema, chronic airflow obstruction, chronic bronchitis, cystic fibrosis, fibrosing alveolitis, pneumoconiosis, pulmonary alveolar proteinosis, pulmonary fibrosis, pulmonary hemosiderosis, persistent pulmonary impairment from COVID-19, radiation pneumonitis, ankylosing spondylitis, bronchopulmonary dysplasia, Guillain-Barré syndrome, other infective polyneuritis, lung cancer, muscular dystrophy, myasthenia gravis, paralysis of the diaphragm, sarcoidosis, and scoliosis. Map your ICD-10-CM code to one of these before submitting.
2. Dyspnea. The member must have dyspnea at rest or with exertion. This needs to be documented in the clinical record—not just noted as a symptom, but tied to the diagnosis.
3. Reduced exercise tolerance. The member's exercise tolerance must be reduced enough to restrict activities of daily living and/or work. Document functional limitations explicitly.
4. Persistent symptoms despite medical management. Symptoms must continue despite appropriate medical treatment. Aetna is looking for evidence that conservative management has already been tried. If that documentation is missing, expect a denial.
5. Moderate to severe functional pulmonary disability. This is the objective threshold, and it requires one of two things:
| # | Covered Indication |
|---|---|
| 1 | A maximal pulmonary exercise stress test under optimal bronchodilatory treatment showing VO2max ≤ 20 ml/kg/min (approximately 5 METs), demonstrating a respiratory limitation to exercise; or |
| 2 | Pulmonary function tests (PFTs) showing FEV1, FVC, FEV1/FVC ratio, or DLCO below 60% of predicted. |
If your patient doesn't have recent PFT results or a cardiopulmonary exercise test on file, get them before submitting a prior authorization request.
6. Member motivation and candidacy. The member must be physically able, motivated, and willing to participate—and a candidate for self-care after the program ends. This is a clinical judgment call, but it needs to be stated explicitly in the record.
7. No disqualifying comorbidities. The member must not have any condition that would imminently worsen pulmonary status or undermine the program's benefits. Aetna specifically lists symptomatic coronary artery disease, congestive heart failure, myocardial infarction within the past six months, dysrhythmia, active joint disease, claudication, and malignancy.
A typical approved course runs up to six weeks or 36 hours of therapy. Plan your authorization requests around that ceiling.
Aetna Pulmonary Rehabilitation Exclusions and Non-Covered Indications
Aetna is direct about what doesn't qualify. These exclusions drive a significant share of claim denials in pulmonary rehab billing.
Repeat programs. Aetna considers repeat pulmonary rehabilitation programs not medically necessary. The only exceptions are patients undergoing lung transplantation or lung volume reduction surgery—where a repeat course is allowed if the underlying procedure is also considered medically necessary.
Maintenance and non-skilled care. Aetna will not cover routine, non-skilled, or maintenance services. This includes:
| # | Excluded Procedure |
|---|---|
| 1 | Repetitive services for chronic baseline conditions |
| 2 | Cases where the patient cannot sustain gains |
| 3 | Cases where the patient has plateaued and shows minimal or no potential for further substantial progress |
| 4 | Cases where there is no overall improvement |
This matters for long-running programs. If your documentation starts showing a plateau, Aetna will not continue reimbursement. Ongoing progress must be documented at each visit.
Very severe pulmonary impairment. Patients with very severe impairment are not eligible. Aetna defines this as dyspnea at rest, difficulty in conversation (one-word answers), inability to work, and cessation of most usual activities resulting in being housebound. These patients are not appropriate candidates for pulmonary rehab per Aetna's guidelines—and submitting claims for them will generate denials regardless of diagnosis.
Coverage Indications at a Glance
| Indication | Status | Relevant Codes | Notes |
|---|---|---|---|
| Chronic pulmonary disease (COPD, asthma, pulmonary fibrosis, cystic fibrosis, etc.) with all seven criteria met | Covered | CPT 94625, 94626 | All seven criteria must be met; verify authorization requirements with Aetna directly |
| Persistent pulmonary impairment from COVID-19 with all seven criteria met | Covered | CPT 94625, 94626 | Must meet all criteria including objective PFT or VO2max threshold |
| Post-lung transplantation pulmonary rehab | Covered | CPT 94625, 94626 | See also CPB 0597, CPB 0598 |
| Post-lung volume reduction surgery | Covered | CPT 94625, 94626 | Exception to the repeat program exclusion |
| Repeat pulmonary rehab (non-transplant, non-surgery) | Not Covered | CPT 94625, 94626 | No exceptions outside transplant or lung volume reduction |
| Maintenance/non-skilled care | Not Covered | CPT 94625, 94626 | Includes plateau in progress, inability to sustain gains |
| Very severe pulmonary impairment (housebound, one-word answers) | Not Covered | CPT 94625, 94626 | Per Aetna guidelines, not appropriate candidates |
| Routine repetitive services for chronic baseline conditions | Not Covered | CPT 94625, 94626 | No reimbursement without documented active progress |
Aetna Pulmonary Rehabilitation Billing Guidelines and Action Items 2026
The effective date of March 7, 2026 is your deadline. Here is what your billing and clinical teams need to do.
| # | Action Item |
|---|---|
| 1 | Audit all active pulmonary rehab authorizations before March 7, 2026. Pull every active auth for CPT 94625 and 94626. Confirm that each patient's chart supports all seven criteria. If any criterion is missing or poorly documented, get it addressed before the effective date. |
| 2 | Confirm objective functional testing is on file for every patient. Aetna requires either a VO2max ≤ 20 ml/kg/min on a cardiopulmonary exercise test or PFT results showing FEV1, FVC, FEV1/FVC, or DLCO below 60% of predicted. This is non-negotiable. No test results, no coverage. Check your EMR for test dates—results must reflect the patient's current status under optimal bronchodilatory treatment. |
| 3 | Update your prior authorization request templates. Your PA documentation must explicitly address all seven criteria. Build a checklist into your intake workflow. Submissions that are missing documentation on motivation and candidacy (criterion six) or concomitant conditions (criterion seven) get denied more often than you'd expect. These feel like soft criteria—they are not. |
| 4 | Flag all repeat program requests for clinical review. If a patient has completed a prior pulmonary rehab course and is being referred for another, confirm whether they have undergone lung transplantation or lung volume reduction surgery. Those are the only approved exceptions. Submit a repeat program request for anyone outside those exceptions and you will get a denial. |
| 5 | Build a progress-documentation protocol for ongoing programs. Maintenance care is explicitly not covered. Your clinical team needs to document active, measurable progress at every visit. When progress plateaus, the program should end—or the authorization will not survive a review. Tie progress notes to specific functional outcomes, not just attendance. |
| 6 | Map your ICD-10-CM codes to Aetna's qualifying diagnosis list. The policy lists specific conditions. Make sure your diagnostic coding reflects one of those conditions clearly. If you bill COVID-19-related persistent pulmonary impairment, document the persistent nature explicitly; it is a covered indication but will draw scrutiny. Confirm your specific ICD-10-CM codes against the full code list in CPB 0032 at the Aetna policy source before submitting claims. |
| 7 | Talk to your compliance officer if you have patients near the very severe threshold. The line between "moderate to severe" and "very severe" pulmonary impairment is clinically meaningful—and financially significant. If you have patients who are largely housebound or rely heavily on ADL assistance, those patients do not qualify under this policy. Submitting claims for them creates audit exposure. If you are not sure where your patient population falls, loop in your compliance officer before the March 7, 2026 effective date. |
| Previous Version | Current Version |
|---|---|
| Coverage is considered experimental and investigational for all indications | Coverage is considered medically necessary when specific criteria are met |
| Prior authorization is not required | Prior authorization is required for initial treatment |
| Documentation must include clinical history | Documentation must include clinical history |
| Re-review every 24 months | Re-review every 12 months with updated clinical documentation |
CPT, HCPCS, and ICD-10 Codes for Pulmonary Rehabilitation Under CPB 0032
Covered CPT Codes — When Selection Criteria Are Met
These are the primary codes for pulmonary rehabilitation billing under CPB 0032.
| Code | Type | Description |
|---|---|---|
| 94625 | CPT | Physician or other qualified health care professional services for outpatient pulmonary rehabilitation (without continuous oximetry monitoring) per session |
| 94626 | CPT | Physician or other qualified health care professional services for outpatient pulmonary rehabilitation (with continuous oximetry monitoring) per session |
HCPCS Codes
CPB 0032 references HCPCS codes as part of the full policy. The source data does not display those codes in full. Review CPB 0032 directly at the Aetna policy source to confirm which HCPCS codes apply to your billing.
ICD-10-CM Diagnosis Codes
The policy references 397 ICD-10-CM codes covering the qualifying diagnoses listed above—including chronic pulmonary diseases, neuromuscular conditions affecting respiration, lung cancer, and COVID-19-related persistent pulmonary impairment. Confirm your specific ICD-10-CM codes against the full code list in CPB 0032 at the Aetna policy source before submitting claims.
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