Aetna modified CPB 0170 for growth hormone therapy, effective October 31, 2025. Here's what billing teams need to know before claims go out the door.
Aetna, a CVS Health company, updated Clinical Policy Bulletin CPB 0170 covering growth hormone (GH) and growth hormone antagonists. This coverage policy governs medical necessity for somatropin products—Genotropin, Humatrope, Norditropin, Nutropin AQ, Omnitrope, Saizen, and Zomacton—across multiple pediatric and adult indications. If your team bills J2941 (somatropin injection) or manages prior authorization for Somavert (pegvisomant), this update belongs on your radar before October 31, 2025.
Quick-Reference Table
| Field | Detail |
|---|---|
| Payer | Aetna |
| Policy | Growth Hormone (GH) and Growth Hormone Antagonists |
| Policy Code | CPB 0170 |
| Change Type | Modified |
| Effective Date | October 31, 2025 |
| Impact Level | High |
| Specialties Affected | Pediatric Endocrinology, Endocrinology, Oncology, Neurology, Specialty Pharmacy |
| Key Action | Audit prior authorization workflows and documentation requirements for all somatropin products before October 31, 2025 |
Aetna Growth Hormone Coverage Criteria and Medical Necessity Requirements 2025
The Aetna growth hormone coverage policy sets specific, layered criteria for each approved indication. Approval is not straightforward. Each indication has its own threshold, and missing a single documentation element is enough to trigger a claim denial.
Pediatric GH Deficiency is the most common indication and the most scrutinized. A member qualifies through one of two paths.
Path one: the member is a neonate, or has a documented neonatal GH deficiency diagnosis—supported by hypoglycemia with random GH level, evidence of multiple pituitary hormone deficiency, or MRI results.
Path two covers older children and requires all four of the following:
| # | Covered Indication |
|---|---|
| 1 | Two pretreatment pharmacologic provocative GH stimulation tests (billed under CPT 80428, 80429, 80430, or 80435), both showing a peak GH level below 10 ng/mL—OR a documented pituitary or CNS disorder plus a pretreatment IGF-1 level more than 2 SD below the mean |
| 2 | For children under 2.5 years: pretreatment height more than 2 SD below the mean with slow growth velocity |
| 3 | For children 2.5 years and older: either pretreatment height more than 2 SD below the mean and 1-year height velocity more than 1 SD below the mean, OR a pretreatment 1-year height velocity more than 2 SD below the mean |
| 4 | Open epiphyses |
IGF-1 (CPT 84305, somatomedin) is covered to monitor adequacy of GH therapy. But Aetna is clear: IGF-1 alone cannot confirm the diagnosis. You still need provocative GH test results in the chart.
Small for Gestational Age (SGA) requires all four criteria:
| # | Covered Indication |
|---|---|
| 1 | Birth weight below 2,500 g at gestational age over 37 weeks, OR birth weight or length below the 3rd percentile, OR birth weight or length 2+ SD below the mean for gestational age |
| 2 | Pretreatment age at least two years |
| 3 | No catch-up growth by age two (pretreatment height more than 2 SD below the mean) |
| 4 | Open epiphyses |
Turner Syndrome requires karyotype confirmation—CPT codes 88280 through 88289 and related molecular cytogenetics codes 88271–88275 and 88291 are referenced in this policy for that purpose.
Somavert (pegvisomant) requires prior authorization for all Aetna participating providers and members in applicable plan designs. Call (866) 752-7021 or fax the SMN form to (888) 267-3277. Do not skip this step—Somavert claims without prior auth will not pay.
Growth hormone billing under this coverage policy means your prior authorization request must document the specific qualifying path, not just the diagnosis code. Reviewers check for the actual lab values, the SD deviations, and the growth velocity measurements. A clean diagnosis on the claim is not enough.
Aetna Growth Hormone Exclusions and Non-Covered Indications
Several testing approaches and drugs are explicitly excluded from coverage under CPB 0170 in the Aetna system. Know these before you submit.
Partial GHD testing is not medically necessary. Aetna will not cover further lab testing in children without classic GHD to diagnose "partial" GHD or other abnormalities of GH secretion or bioactivity. This includes overnight hospitalization for spontaneous GH secretion testing. If a physician orders this, document why it doesn't fall under that exclusion—or don't bill it to Aetna.
IGF binding proteins are experimental. Measurement of IGFBP-2, IGFBP-3, and the acid labile subunit of IGF-1 are considered experimental, investigational, or unproven. Billing these as support for a GH deficiency diagnosis will not fly. The policy is direct about this.
Semorelin (Q0515) is not covered for the indications listed in CPB 0170. This is an explicit HCPCS-level exclusion.
Stem cell harvesting codes 38205 and 38206 (blood-derived hematopoietic progenitor cell harvesting) are also listed as not covered for the indications in this bulletin.
The real risk here is diagnostic testing billing. Billing IGFBP-3 or IGFBP-2 alongside a GH deficiency workup will generate a denial—and possibly a recoupment request if it slips through initially.
Coverage Indications at a Glance
| Indication | Status | Relevant Codes | Notes |
|---|---|---|---|
| Pediatric GH Deficiency (neonatal) | Covered | J2941, 83003, 84305 | MRI or lab evidence required; CPT 70551–70553 for MRI |
| Pediatric GH Deficiency (non-neonatal) | Covered | J2941, 80428–80430, 80435, 84305 | Two provocative GH tests required; IGF-1 for monitoring |
| Small for Gestational Age (SGA) | Covered | J2941 | Birth weight/length criteria + no catch-up growth by age 2 |
| Turner Syndrome | Covered | J2941, 88280–88289, 88291 | Karyotype confirmation required |
| Somavert (Pegvisomant) | Covered with Prior Auth | J2940, J2941 | Prior auth mandatory; call (866) 752-7021 |
| Partial GHD (non-classic) | Not Covered | — | Testing and overnight hospitalization for spontaneous GH secretion excluded |
| IGFBP-2, IGFBP-3, Acid Labile Subunit | Experimental / Not Covered | — | Not medically necessary for GH deficiency diagnosis |
| Semorelin (Semorelin Acetate) | Not Covered | Q0515 | Explicit HCPCS exclusion |
| Stem Cell Harvesting (allogenic/autologous) | Not Covered | 38205, 38206 | Excluded for indications in this CPB |
Aetna Growth Hormone Billing Guidelines and Action Items 2025
The effective date of October 31, 2025 is your deadline. Work backward from there.
| # | Action Item |
|---|---|
| 1 | Audit your Somavert prior authorization workflow now. Every Somavert (pegvisomant) claim needs prior auth before it goes out. Confirm your team has the correct fax number (888-267-3277) and call line (866-752-7021) in your workflow. One missed step here kills reimbursement entirely. |
| 2 | Verify provocative GH test documentation for every pediatric GHD case. Two pharmacologic stimulation tests (CPT 80428, 80429, 80430, or 80435) with peak GH below 10 ng/mL are required for non-neonatal pediatric GHD. Pull the lab reports. If they're not in the chart, the claim will not survive a review. |
| 3 | Stop billing IGFBP-2 and IGFBP-3 in support of GH deficiency diagnoses on Aetna claims. These are experimental under CPB 0170. If your physicians are ordering them, flag it with your medical director before October 31, 2025. Claims that slip through now may get recouped later. |
| 4 | Check your IGF-1 documentation. CPT 84305 (somatomedin) is covered for monitoring adequacy of GH therapy—not for standalone diagnosis. Make sure your billing team is coding this to monitoring, not to diagnosis confirmation. |
| 5 | Build a Turner Syndrome documentation checklist. Karyotype confirmation is required. Chromosome analysis codes 88280–88289 and 88291, plus molecular cytogenetics 88271–88275, are referenced in this policy. If a karyotype isn't documented, the somatropin authorization won't hold. |
| 6 | Flag SGA cases for birth record documentation. All three birth criteria options require specific measurements. Make sure your office has the birth weight, gestational age, and growth percentile data before submitting. Missing a single data point stalls the prior auth. |
| 7 | Confirm MRI ordering for CNS disorder pathway cases. If a member qualifies under the pituitary/CNS disorder path (instead of two provocative tests), document the MRI result. CPT 70551, 70552, and 70553 are referenced in this policy for brain MRI. The IGF-1 must also show greater than 2 SD below the mean. |
If your team handles a high volume of specialty pharmacy billing for somatropin products, talk to your compliance officer before the effective date. The multi-criteria structure here creates documentation gaps that auditors find quickly.
| 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 Growth Hormone Under CPB 0170
Covered CPT Codes (When Selection Criteria Are Met)
| Code | Type | Description |
|---|---|---|
| 80418 | CPT | Combined rapid anterior pituitary evaluation panel |
| 80422 | CPT | Glucagon tolerance panel; for insulinoma |
| 80428 | CPT | Growth hormone stimulation panel |
| 80429 | CPT | Growth hormone stimulation panel |
| 80430 | CPT | Growth hormone stimulation panel |
| 80434 | CPT | Insulin tolerance panel; for ACTH insufficiency |
| 80435 | CPT | Insulin tolerance panel; for growth hormone deficiency |
| 82943 | CPT | Glucagon |
| 82946 | CPT | Glucagon tolerance test |
| 82947 | CPT | Glucose; quantitative, blood (macimorelin stimulation test) |
| 83003 | CPT | Growth hormone, human (HGH) (somatotropin) |
| 84305 | CPT | Somatomedin (IGF-1) |
| 84436 | CPT | Thyroxine; total |
| 86277 | CPT | Growth hormone, human (HGH), antibody |
| 88271 | CPT | Molecular cytogenetics |
| 88272 | CPT | Molecular cytogenetics |
| 88273 | CPT | Molecular cytogenetics |
| 88274 | CPT | Molecular cytogenetics |
| 88275 | CPT | Molecular cytogenetics |
| 88280 | CPT | Chromosome analysis |
| 88281 | CPT | Chromosome analysis |
| 88282 | CPT | Chromosome analysis |
| 88283 | CPT | Chromosome analysis |
| 88284 | CPT | Chromosome analysis |
| 88285 | CPT | Chromosome analysis |
| 88286 | CPT | Chromosome analysis |
| 88287 | CPT | Chromosome analysis |
| 88288 | CPT | Chromosome analysis |
| 88289 | CPT | Chromosome analysis |
| 88291 | CPT | Cytogenetics and molecular cytogenetics, interpretation and report |
| 70450–70470 | CPT | Computed tomography, head or brain (multiple variants) |
| 70496 | CPT | Computed tomography angiography, head |
| 70551 | CPT | MRI, brain; without contrast |
| 70552 | CPT | MRI, brain; with contrast |
| 70553 | CPT | MRI, brain; without and with contrast |
| 70554 | CPT | MRI, brain, functional MRI |
| 70555 | CPT | MRI, brain, functional MRI |
| 96372 | CPT | Therapeutic, prophylactic or diagnostic injection; subcutaneous or intramuscular |
| 99601 | CPT | Home infusion/specialty drug administration |
| 99602 | CPT | Home infusion/specialty drug administration |
Not Covered / Experimental CPT Codes
| Code | Type | Description | Reason |
|---|---|---|---|
| 38205 | CPT | Blood-derived hematopoietic progenitor cell harvesting; allogenic | Not covered for indications listed in CPB 0170 |
| 38206 | CPT | Blood-derived hematopoietic progenitor cell harvesting; autologous | Not covered for indications listed in CPB 0170 |
HCPCS Codes
| Code | Type | Description | Status |
|---|---|---|---|
| J2940 | HCPCS | Injection, somatrem, 1 mg | Covered (no specific HCPCS for Somavert/Sogroya; J2940/J2941 used) |
| J2941 | HCPCS | Injection, somatropin, 1 mg | Covered (primary billing code for somatropin products) |
| S9558 | HCPCS | Home injectable therapy; growth hormone | Other covered HCPCS |
| S9364–S9368 | HCPCS | Home infusion therapy, total parenteral nutrition (TPN) | Other covered HCPCS |
| B4164–B5200 | HCPCS | Parenteral nutrition solutions and supplies | Other covered HCPCS |
| B9004 | HCPCS | Parenteral nutrition infusion pump | Other covered HCPCS |
| B9005 | HCPCS | Parenteral nutrition infusion pump | Other covered HCPCS |
| B9006 | HCPCS | Parenteral nutrition infusion pump | Other covered HCPCS |
| Q0515 | HCPCS | Injection, semorelin acetate, 1 mcg | Not covered for indications listed in CPB 0170 |
Key ICD-10-CM Diagnosis Codes
| Code | Description |
|---|---|
| B20 | Human immunodeficiency virus (HIV) disease |
| C71.0 | Malignant neoplasm of cerebrum, except lobes and ventricles |
| C71.1 | Malignant neoplasm of frontal lobe |
| C71.2 | Malignant neoplasm of temporal lobe |
| C71.3 | Malignant neoplasm of parietal lobe |
Note: The full ICD-10-CM code set for CPB 0170 includes 403 codes. See the full policy on PayerPolicy for the complete list.
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