TL;DR: Aetna, a CVS Health company, modified CPB 0184 covering pulmonary hypertension treatments and prostanoid indications, effective September 26, 2025. Billing teams handling PAH drug precertification and infusion codes — including J1325, J3285, J7686, Q4074, and infusion series 96365–96371 — need to verify their workflows match the updated criteria before claims go out.
This update to the Aetna pulmonary hypertension coverage policy touches a broad set of codes and treatment categories. The policy covers prostanoids, endothelin receptor antagonists, PDE-5 inhibitors, soluble guanylate cyclase stimulators, and now sotatercept-csrk (Winrevair) — plus procedural codes for right heart catheterization (93541), wireless PA pressure sensor implantation (33289), balloon angioplasty (92997, 92998), and atrial septostomy (33741). If your practice or facility bills any of these, CPB 0184 in the Aetna system is your governing document.
Quick-Reference Table
| Field | Detail |
|---|---|
| Payer | Aetna, a CVS Health company |
| Policy | Pulmonary Hypertension Treatments and Selected Indications of Prostanoids |
| Policy Code | CPB 0184 |
| Change Type | Modified |
| Effective Date | September 26, 2025 |
| Impact Level | High |
| Specialties Affected | Pulmonology, Cardiology, Infusion Therapy, Specialty Pharmacy, Cardiovascular Surgery |
| Key Action | Verify precertification workflows for all PAH drug categories and confirm sotatercept-csrk (Winrevair) billing under updated criteria before submitting claims |
Aetna Pulmonary Hypertension Coverage Criteria and Medical Necessity Requirements 2025
The Aetna pulmonary hypertension coverage policy under CPB 0184 requires precertification for all pulmonary arterial hypertension (PAH) drugs. This applies to every Aetna participating provider and member in applicable plan designs — no exceptions.
To get precertification for PAH drugs, call (866) 752-7021 for commercial plans or fax a Statement of Medical Necessity form to (888) 267-3277. Don't assume your standard prior authorization process covers this. Aetna routes PAH drug precertification separately from general prior auth, and using the wrong channel delays approval and risks a claim denial.
The medical necessity threshold for many procedural codes under this policy is a pulmonary vascular resistance index (PVRI) greater than 3 Wood units. This applies to CPT codes 33289 (wireless PA pressure sensor implantation), 93541 (right heart catheterization), and the infusion series 96365 through 96371. If your documentation doesn't show PVRI data meeting that threshold, your claim won't survive a medical necessity review.
The policy explicitly separates commercial plan criteria from Medicare. If you bill Medicare Advantage or traditional Medicare through Aetna, look at the Medicare Part B criteria separately — CPB 0184 does not govern those claims.
Reimbursement for oral sildenafil deserves a specific callout. HCPCS S0090 — sildenafil citrate 25 mg — is listed in this policy but carries a note: it is not covered in oral form for pulmonary hypertension. If your team has been billing S0090 for oral sildenafil in PAH patients, stop. That's a denial waiting to happen.
Preferred agent status also matters here. Aetna directs providers to a separate Pharmacy Clinical Policy Bulletin on preferred agents for pulmonary hypertension. What's covered under CPB 0184 isn't automatically on the preferred list. Check the formulary CPB before assuming a covered drug gets full reimbursement.
Aetna Pulmonary Hypertension Exclusions and Non-Covered Indications
A few specific exclusions stand out in this policy. Pulmonary artery denervation is not covered for ICD-10 I27.0 (primary pulmonary hypertension). This is worth noting because denervation has gained attention in interventional cardiology, and some teams assume coverage follows clinical interest. It doesn't here.
Oral sildenafil billed via S0090 is excluded, as noted above. This is a common source of unexpected denials in practices treating PAH with off-label PDE-5 inhibitors.
Sotatercept-csrk (Winrevair) has no specific HCPCS code assigned yet. The policy flags this drug under the group label "Sotatercept-csrk (Winrevair) — no specific code." Billing teams should watch for HCPCS code assignments from CMS and Aetna guidance updates. Until a code is assigned, billing this drug requires careful coordination with your specialty pharmacy and compliance officer.
Coverage Indications at a Glance
| Indication / Treatment | Status | Relevant Codes | Notes |
|---|---|---|---|
| PAH drugs (all categories) | Covered with precertification | J1325, J3285, J7686, Q4074, E0782, E0783 | Precertification required — call (866) 752-7021 |
| IV/SubQ infusion for PAH | Covered when PVRI >3 Wood units | 96365–96371 | PVRI documentation required |
| Right heart catheterization | Covered when PVRI >3 Wood units | 93541 | Used to establish PVRI threshold |
| Wireless PA pressure sensor implant | Covered when PVRI >3 Wood units | 33289 | Long-term hemodynamic monitoring |
| Pulmonary artery balloon angioplasty | Covered if selection criteria met | 92997, 92998 | Percutaneous transluminal approach |
| Transcatheter atrial septostomy | Covered if selection criteria met | 33741 | Congenital cardiac anomalies indication |
| Implantable infusion pump (nonprogrammable) | Covered if selection criteria met | E0782 | DME — confirm plan design coverage |
| Implantable infusion pump (programmable) | Covered if selection criteria met | E0783 | DME — confirm plan design coverage |
| Imatinib 100 mg | Covered if selection criteria met | S0088 | Off-label PAH use — medical necessity documentation required |
| Sotatercept-csrk (Winrevair) | Covered with criteria — no HCPCS code assigned | None yet | Monitor for code assignment; coordinate with specialty pharmacy |
| Oral sildenafil for PAH | Not covered | S0090 | Excluded in oral form for PAH |
| Pulmonary artery denervation | Not covered | I27.0 | Excluded specifically for primary pulmonary hypertension |
Aetna Pulmonary Hypertension Billing Guidelines and Action Items 2025
| # | Action Item |
|---|---|
| 1 | Update your precertification workflow before submitting any PAH drug claims dated September 26, 2025 or later. Confirm your team uses the commercial precertification line — (866) 752-7021 — not the standard prior authorization channel. Route SMN forms to fax (888) 267-3277. A misrouted precertification request is a denial you didn't need. |
| 2 | Pull PVRI documentation for every infusion claim using 96365–96371 and every 93541 claim. The medical necessity threshold is PVRI greater than 3 Wood units. If your right heart cath report doesn't include PVRI, your claim for infusion therapy won't hold up on review. Get the documentation before the claim goes out, not after a denial. |
| 3 | Flag S0090 in your charge capture system as non-covered for PAH indications. Oral sildenafil for pulmonary hypertension is explicitly excluded. If your team has been billing S0090 for these patients, run a 90-day lookback and assess your exposure. Talk to your compliance officer before you decide how to handle any prior submissions. |
| 4 | Check the Aetna Pharmacy CPB for preferred agent status before billing J1325, J3285, J7686, or Q4074. Coverage under CPB 0184 and preferred formulary status are separate determinations. A covered drug on a non-preferred tier can still generate significant patient cost-share disputes or require step therapy documentation you don't have yet. |
| 5 | Hold Winrevair (sotatercept-csrk) claims and monitor for HCPCS code assignment. There is no billable HCPCS code for this drug under this policy as of the September 26, 2025 effective date. Work with your specialty pharmacy on a billing strategy. If you're not sure how to handle the gap, loop in your billing consultant before the claim goes out. |
| 6 | Verify DME coverage under E0782 and E0783 at the plan design level. Implantable infusion pump reimbursement under this policy depends on the member's specific plan design. Run an eligibility and benefits check that includes DME coverage before any implant procedure. |
| 7 | Confirm ICD-10 code specificity for all PAH claims. The policy maps to a large set of diagnosis codes — including I27.0, I27.20–I27.29, I27.83, and I50.x codes for heart failure, among others. Vague coding to I27.0 for a patient with secondary PAH, or using an unspecified I27.2x code when a specific subtype is documented, creates both a medical necessity risk and a coding audit flag. |
| 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 Hypertension Treatments Under CPB 0184
Covered CPT Codes (When Selection Criteria Are Met)
| Code | Type | Description |
|---|---|---|
| 33741 | CPT | Transcatheter atrial septostomy (TAS) for congenital cardiac anomalies to create effective atrial flow |
| 92997 | CPT | Percutaneous transluminal pulmonary artery balloon angioplasty |
| 92998 | CPT | Percutaneous transluminal pulmonary artery balloon angioplasty (additional vessel) |
CPT Codes Covered When PVRI >3 Wood Units
| Code | Type | Description |
|---|---|---|
| 33289 | CPT | Transcatheter implantation of wireless pulmonary artery pressure sensor for long-term hemodynamic monitoring |
| 93541 | CPT | Right heart catheterization including measurement of oxygen saturation and cardiac output |
| 96365 | CPT | IV infusion, initial, up to 1 hour |
| 96366 | CPT | IV infusion, each additional hour |
| 96367 | CPT | IV infusion, additional sequential infusion, up to 1 hour |
| 96368 | CPT | IV infusion, concurrent infusion |
| 96369 | CPT | SubQ infusion therapy, initial, up to 1 hour |
| 96370 | CPT | SubQ infusion therapy, each additional hour |
| 96371 | CPT | SubQ infusion therapy, additional pump |
Covered HCPCS Codes (When Selection Criteria Are Met)
| Code | Type | Description | Notes |
|---|---|---|---|
| E0782 | HCPCS | Infusion pump, implantable, nonprogrammable (includes all components) | DME — verify plan design |
| E0783 | HCPCS | Infusion pump system, implantable, programmable (includes all components) | DME — verify plan design |
| S0088 | HCPCS | Imatinib, 100 mg | Medical necessity documentation required |
| J1325 | HCPCS | Injection, epoprostenol, 0.5 mg | Precertification required |
| J3285 | HCPCS | Injection, treprostinil, 1 mg | Precertification required |
| J7686 | HCPCS | Treprostinil, inhalation solution, FDA-approved, non-compounded, administered through DME | Precertification required |
| Q4074 | HCPCS | Iloprost, inhalation solution, FDA-approved, non-compounded, administered through DME | Precertification required |
Non-Covered HCPCS Codes
| Code | Type | Description | Reason |
|---|---|---|---|
| S0090 | HCPCS | Sildenafil citrate, 25 mg (phosphodiesterase 5 inhibitor) | Not covered in oral form for pulmonary hypertension |
No HCPCS Code Assigned (Monitor for Updates)
| Drug | Status |
|---|---|
| Sotatercept-csrk (Winrevair) | Covered with criteria — no specific HCPCS code assigned as of September 26, 2025 |
Key ICD-10-CM Diagnosis Codes
| Code | Description |
|---|---|
| I27.0 | Primary pulmonary hypertension (not covered for pulmonary artery denervation) |
| I27.20 | Pulmonary hypertension, unspecified |
| I27.21 | Secondary pulmonary arterial hypertension |
| I27.22 | Pulmonary hypertension due to left heart disease |
| I27.23 | Pulmonary hypertension due to lung diseases and hypoxia |
| I27.24 | Chronic thromboembolic pulmonary hypertension |
| I27.25 | Pulmonary hypertension with unclear multifactorial mechanisms |
| I27.26 | Pulmonary hypertension, other |
| I27.27 | Pulmonary hypertension, specified |
| I27.28 | Other secondary pulmonary hypertension |
| I27.29 | Other secondary pulmonary hypertension, unspecified |
| I27.83 | Eisenmenger's syndrome |
| I50.1–I50.9 | Heart failure (multiple codes) |
| I70.0–I70.29 | Atherosclerosis (multiple codes) |
| C96.0 | Multifocal and multisystemic (disseminated) Langerhans-cell histiocytosis |
| C96.5 | Multifocal and unisystemic Langerhans-cell histiocytosis |
| C96.6 | Unifocal Langerhans-cell histiocytosis |
| E66.2 | Morbid (severe) obesity with alveolar hypoventilation |
| G61.81 | Chronic inflammatory demyelinating polyneuritis |
| G71.0–G71.9 | Muscular dystrophy (multiple codes) |
Note: CPB 0184 references 183 ICD-10-CM codes in total. The codes above represent the PAH-specific and directly policy-relevant diagnoses. Review the full code list at the Aetna CPB 0184 source document before finalizing your charge capture mapping.
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