Aetna modified CPB 0202 for magnetic resonance spectroscopy (MRS), effective September 26, 2025. Here's what changes for billing teams.
Aetna, a CVS Health company, updated its MRS coverage policy under CPB 0202 Aetna system, governing CPT 76390 for magnetic resonance spectroscopy. The policy defines the specific neurological and metabolic conditions where MRS is medically necessary — and clearly separates those from a set of category III codes (0609T, 0610T, 0611T, 0612T) that Aetna will not cover. If your team bills MRS for brain tumor evaluation, metabolic disorders, or leukodystrophies, this policy directly affects your reimbursement and claim denial exposure.
Quick-Reference Table
| Field | Detail |
|---|---|
| Payer | Aetna, a CVS Health company |
| Policy | Magnetic Resonance Spectroscopy (MRS) — CPB 0202 |
| Policy Code | CPB 0202 |
| Change Type | Modified |
| Effective Date | September 26, 2025 |
| Impact Level | Medium — specific indications covered; broad non-coverage for category III codes |
| Specialties Affected | Neurology, Neuro-oncology, Pediatric Neurology, Radiology, Neuroradiology |
| Key Action | Verify that CPT 76390 claims map to an approved ICD-10 diagnosis; do not bill 0609T–0612T for Aetna patients |
Aetna Magnetic Resonance Spectroscopy Coverage Criteria and Medical Necessity Requirements 2025
The Aetna MRS coverage policy under CPB 0202 is more permissive than many billing teams expect — but only for specific, well-defined diagnoses. Medical necessity is established for six categories of indications, all centered on brain and CNS conditions.
Brain tumor evaluation is the most common billing scenario. Aetna covers CPT 76390 to distinguish low-grade from high-grade gliomas, to evaluate a brain lesion of indeterminate nature when MRS results will determine whether biopsy or resection can be safely postponed, and to distinguish recurrent brain tumor from radiation-induced tumor necrosis. That last one matters — post-treatment surveillance is frequently where claim denial happens when the indication isn't documented clearly.
Hypoxic ischemic encephalopathy (HIE) is covered for prognostic assessment. This applies primarily in neonatal settings. Document the clinical purpose explicitly: prognostic use, not diagnostic workup.
Metabolic disorders represent a large portion of the covered ICD-10 list. Aetna covers MRS for diagnosis and monitoring of Canavan disease, creatine deficiency, nonketotic hyperglycinemia, and Maple Syrup Urine disease. For monitoring specifically, the policy adds a condition: recent MRI findings must be inconclusive and a change in therapy must be under consideration. If both aren't true, the medical necessity argument doesn't hold.
Leukodystrophies and related white matter disorders are covered for diagnosis only (not routine monitoring) — unless, again, MRI is inconclusive and therapy change is being considered. The covered diagnoses here are:
| # | Covered Indication |
|---|---|
| 1 | Metachromatic leukodystrophy (MCL) |
| 2 | Pelizaeus-Merzbacher disease (PMD) |
| 3 | Hypomyelination and Congenital Cataract |
| 4 | Globoid Cell Leukodystrophy (Krabbe disease) |
| 5 | X-linked adrenoleukodystrophy (X-ALD, CALD) |
| 6 | Mitochondrial disorders (Leigh's syndrome, Kearns-Sayre syndrome, MELAS, and others) |
| 7 | Alexander disease (ALX, AXD, demyelinogenic leukodystrophy) |
| 8 | Megalencephalic leukoencephalopathy with subcortical cysts |
| 9 | Vanishing White Matter disease (CACH/VWM) |
This is a precise list. If your patient has a different leukodystrophy not on it, don't assume coverage. The policy doesn't mention prior authorization requirements specifically for CPT 76390, but Aetna's general radiology prior auth rules likely apply — check the member's specific plan before scheduling.
Aetna Magnetic Resonance Spectroscopy Exclusions and Non-Covered Indications
Aetna explicitly excludes coverage for CPT codes 0609T, 0610T, 0611T, and 0612T. These are category III codes for a specific MRS application: determination and localization of discogenic pain (cervical and thoracic spine), plus the associated data transmission, postprocessing, and interpretation components.
This is a clean, hard exclusion. Aetna does not cover MRS for spinal pain workup under this coverage policy — period. If you're in a spine or pain management practice billing these codes, stop. They will deny.
There's also a diagnostic carve-out worth knowing for brain tumor cases. The ICD-10 codes for malignant neoplasms of the brain (C71.0–C71.9) and secondary malignant neoplasm of the brain (C79.31) carry a specific note: MRS is not covered for differentiating primary central nervous system (CNS) lymphoma from other brain lesions when that is the stated purpose. The covered brain tumor indications (glioma grading, tumor vs. necrosis) still apply. But if the clinical question in your documentation is "rule out CNS lymphoma," expect a denial.
The ICD-10 code C72.9 (malignant neoplasm of the CNS, unspecified) is specifically associated with primary CNS lymphoma in this policy. Tag it accordingly in your documentation review.
Coverage Indications at a Glance
| Indication | Status | Primary CPT Code | Notes |
|---|---|---|---|
| Hypoxic ischemic encephalopathy — prognostic assessment | Covered | 76390 | Document clinical purpose as prognostic |
| Distinguish low-grade vs. high-grade glioma | Covered | 76390 | Brain tumor staging context |
| Indeterminate brain lesion — biopsy/resection decision | Covered | 76390 | MRS findings must inform biopsy/resection timing |
| Recurrent brain tumor vs. radiation necrosis | Covered | 76390 | Post-treatment surveillance; document clearly |
| Canavan disease — diagnosis and monitoring | Covered | 76390 | Monitoring requires inconclusive MRI + therapy change consideration |
| Creatine deficiency — diagnosis and monitoring | Covered | 76390 | Same monitoring conditions apply |
| Nonketotic hyperglycinemia — diagnosis and monitoring | Covered | 76390 | Same monitoring conditions apply |
| Maple Syrup Urine disease — diagnosis and monitoring | Covered | 76390 | Same monitoring conditions apply |
| Metachromatic leukodystrophy (MCL) | Covered | 76390 | Monitoring only if MRI inconclusive + therapy change considered |
| Pelizaeus-Merzbacher disease (PMD) | Covered | 76390 | Monitoring only if MRI inconclusive + therapy change considered |
| Hypomyelination and Congenital Cataract | Covered | 76390 | Monitoring only if MRI inconclusive + therapy change considered |
| Krabbe disease (Globoid Cell Leukodystrophy) | Covered | 76390 | Monitoring only if MRI inconclusive + therapy change considered |
| X-linked adrenoleukodystrophy (X-ALD, CALD) | Covered | 76390 | Monitoring only if MRI inconclusive + therapy change considered |
| Mitochondrial disorders (Leigh's, MELAS, Kearns-Sayre, etc.) | Covered | 76390 | Monitoring only if MRI inconclusive + therapy change considered |
| Alexander disease | Covered | 76390 | Monitoring only if MRI inconclusive + therapy change considered |
| Megalencephalic leukoencephalopathy with subcortical cysts | Covered | 76390 | Monitoring only if MRI inconclusive + therapy change considered |
| Vanishing White Matter disease (CACH/VWM) | Covered | 76390 | Monitoring only if MRI inconclusive + therapy change considered |
| Discogenic pain localization — cervical/thoracic spine | Not Covered | 0609T–0612T | Hard exclusion; all four codes denied |
| MRS to differentiate CNS lymphoma from other brain lesions | Not Covered | 76390 | C71.x, C72.9, C79.31 carry this exclusion note |
Aetna Magnetic Resonance Spectroscopy Billing Guidelines and Action Items 2025
The effective date is September 26, 2025. If your team hasn't reviewed your charge capture and documentation templates since that date, start now.
| # | Action Item |
|---|---|
| 1 | Audit all CPT 76390 claims billed to Aetna after September 26, 2025. Confirm each claim maps to one of the covered indications in CPB 0202. Any claim with a diagnosis code that doesn't appear in the covered list is a denial risk. Pull a 90-day report and review. |
| 2 | Remove 0609T, 0610T, 0611T, and 0612T from your Aetna charge master or payer-specific fee schedule. These codes are not covered under any indication. Billing them generates claim denial with no appeal path under this coverage policy. If your EMR auto-populates these for spine MRS orders, suppress them for Aetna patients at the point of order entry. |
| 3 | Update your MRS order templates to capture the clinical question explicitly. For brain tumor cases, the documentation must state the specific question being answered — glioma grading, biopsy timing, or tumor vs. necrosis. "MRS brain" with a C71.x code is not enough. If the order says "rule out CNS lymphoma," the claim will deny. |
| 4 | For monitoring MRS claims on leukodystrophy or metabolic disorder patients, add a two-part documentation requirement. The clinician note must state: (a) recent MRI findings were inconclusive, and (b) a change in therapy is under consideration. Both conditions must be present. One without the other doesn't meet medical necessity under this policy. |
| 5 | Confirm prior authorization status before scheduling MRS for any Aetna member. This policy doesn't list MRS as exempt from Aetna's radiology prior auth requirements. MRS billing without a valid prior auth — when required by the member's plan — is the fastest route to a denial that documentation alone won't fix. Verify at the plan level, not just the policy level. |
| 6 | If you're in a practice with complex CNS lymphoma workups, loop in your compliance officer. The carve-out for CNS lymphoma differentiation under C71.x and C72.9 creates a documentation gray zone. If your physicians are ordering MRS in a workup that touches both CNS lymphoma and glioma staging, the claim rationale needs to be airtight before it goes out. |
| 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 Magnetic Resonance Spectroscopy Under CPB 0202
Covered CPT Codes (When Selection Criteria Are Met)
| Code | Type | Description |
|---|---|---|
| 76390 | CPT | Magnetic resonance spectroscopy |
Not Covered / Experimental Codes
| Code | Type | Description | Reason |
|---|---|---|---|
| 0609T | CPT | Magnetic resonance spectroscopy, determination and localization of discogenic pain (cervical, thoracic) | Not covered for any indication under CPB 0202 |
| 0610T | CPT | Transmission of biomarker data for software analysis | Not covered for any indication under CPB 0202 |
| 0611T | CPT | Postprocessing for algorithmic analysis of biomarker data for determination of relative chemical differences | Not covered for any indication under CPB 0202 |
| 0612T | CPT | Interpretation and report | Not covered for any indication under CPB 0202 |
Key ICD-10-CM Diagnosis Codes
The full policy includes 614 ICD-10-CM codes. Below are the highest-volume and highest-risk codes for MRS billing teams:
| Code | Description | Coverage Note |
|---|---|---|
| C71.0–C71.9 | Malignant neoplasm of brain | Covered for glioma grading, tumor vs. necrosis — NOT for CNS lymphoma differentiation |
| C72.9 | Malignant neoplasm of central nervous system, unspecified | Associated with CNS lymphoma; not covered for lymphoma differentiation |
| C79.31 | Secondary malignant neoplasm of brain | Not covered for CNS lymphoma differentiation |
| C79.49 | Secondary malignant neoplasm of spinal cord | Covered per policy list |
| C61 | Malignant neoplasm of prostate | Included in covered ICD-10 list |
| C50.011–C50.929 | Malignant neoplasm of breast (male and female) | Included in covered ICD-10 list |
| C79.81 | Secondary malignant neoplasm of breast | Included in covered ICD-10 list |
| C79.82 | Secondary malignant neoplasm of genital organs (prostate) | Included in covered ICD-10 list |
| D05.0–D05.3x | Carcinoma in situ of breast | Included in covered ICD-10 list |
| A69.20–A69.29 | Lyme disease | Included in covered ICD-10 list |
| C15.3–C15.9 | Malignant neoplasm of esophagus | Included in covered ICD-10 list |
| C22.0–C22.9 | Malignant neoplasm of liver and intrahepatic bile ducts | Included in covered ICD-10 list |
The full 614-code ICD-10 list is available in the source policy at CPB 0202 on Aetna's clinical policy portal. Cross-reference your active diagnosis codes against that list before billing.
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