Multiple Sclerosis — CPB 0264 | AETNA Coverage Update

Aetna modified CPB 0264 for multiple sclerosis drug coverage, effective January 10, 2026. Here's what billing teams need to know before submitting claims.

Aetna, a CVS Health company, updated Clinical Policy Bulletin CPB 0264 governing MS disease-modifying therapy coverage for commercial plans. The revision affects prior authorization requirements and medical necessity criteria for six high-cost infusion drugs—Briumvi, Lemtrada, Ocrevus, Ocrevus Zunovo, Tyruko, and Tysabri—along with a wide set of associated CPT and HCPCS codes spanning infusion administration, apheresis, stem cell procedures, and diagnostic testing. If your practice bills for MS infusion therapy or your revenue cycle team manages specialty drug authorizations, this policy change affects your workflow now.

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Quick-Reference: Aetna CPB 0264 Multiple Sclerosis Coverage Policy 2026

Field	Detail
Payer	Aetna, a CVS Health company
Policy	Multiple Sclerosis — CPB 0264
Policy Code	CPB 0264
Change Type	Modified
Effective Date	January 10, 2026
Impact Level	High
Specialties Affected	Neurology, Infusion Centers, Specialty Pharmacy, Hematology/Oncology (for HSCT-related MS treatment)
Key Action	Verify prior authorization is current for all six named infusion drugs before billing CPT 96413–96417 or 96365–96368 on any commercial Aetna plan

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Aetna Multiple Sclerosis Coverage Criteria and Medical Necessity Requirements 2026

The Aetna multiple sclerosis coverage policy under CPB 0264 draws hard lines around which patients qualify for high-cost MS therapy and under what conditions. Each drug gets its own criteria. Not knowing them is the fastest route to a claim denial.

Lemtrada (alemtuzumab) has the tightest medical necessity bar. For a first course, the member must have a relapsing form of MS—including relapsing-remitting or secondary progressive MS with continued relapse—and must have had an inadequate response to two or more MS drugs. That step therapy requirement is non-negotiable. For subsequent courses, treatment must start at least 12 months after the last dose of the prior course. Aetna will not cover Lemtrada used alongside other disease-modifying MS agents. Ampyra and Nuedexta are exceptions—Aetna does not classify them as disease-modifying, so concurrent use is allowed.

Prior authorization is required for all six infusion drugs: Briumvi, Lemtrada, Ocrevus, Ocrevus Zunovo, Tyruko, and Tysabri. Call (866) 752-7021 or fax your Statement of Medical Necessity form to (888) 267-3277. This is not optional for participating providers or members in applicable plan designs. If your team is submitting claims for these drugs without an active authorization on file, stop and verify before the next billing cycle.

Site of care also matters for reimbursement. Aetna's Site of Care Utilization Management Policy applies to all six infusion drugs on commercial plans. That means Aetna may redirect infusions from hospital outpatient settings to lower-cost alternatives. If your facility bills CPT 96365–96368 or CPT 96413–96417 in a hospital outpatient setting, expect site-of-care review. Denials from site-of-care mismatches are among the most preventable in MS infusion billing.

Pediatric members under 18 can receive Lemtrada authorization when the prescribing neurologist documents that benefits outweigh risks. This requires neurologist prescribing or documented consultation—a physician specialist requirement that your credentialing and referral workflows need to support.

For oral and self-administered MS therapies—including Tecfidera, Gilenya, Kesimpta, Copaxone, Mavenclad, Zeposia, Mayzent, Aubagio, and Vumerity—Aetna directs coverage to its Pharmacy Clinical Policy Bulletins, not CPB 0264. The same applies to interferon beta products (Rebif, Betaseron, Extavia, Plegridy). Tysabri is managed under CPB 0264 and requires precertification per that policy. Know which policy governs each drug before you submit.

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Aetna Multiple Sclerosis Exclusions and Non-Covered Indications

This coverage policy lists several explicit exclusions. They show up at the claim level when the wrong code is submitted or the documentation doesn't support the indication.

Plasma pheresis (CPT 36514) is covered under this policy for some MS indications, but not for chronic or secondary progressive MS. That distinction is embedded in the code description. Aetna considers all uses of alemtuzumab (Lemtrada) outside the defined relapsing MS criteria to be experimental, investigational, or unproven. There is no pathway to coverage for off-label alemtuzumab outside those criteria.

CD34 stem cell measurement (CPT 86367) is not covered for measuring hematopoietic stem and progenitor cell populations in MS. Billing it in that context will not result in reimbursement. Hyperbaric oxygen therapy (CPT 99183), hypnotherapy (CPT 90880), PUVA photochemotherapy (CPT 96912, 96913), and photopheresis (CPT 36522) all appear in the code set but are not covered for MS under this policy. If your practice offers any of these as complementary or adjunctive services for MS patients, do not submit them under CPB 0264 criteria—they will deny.

The policy also calls out several diagnostic and monitoring codes as experimental in the MS context. Interleukin-1 gene polymorphism testing, NOGO receptor quantitative MRI analysis (CPT 0865T and 0866T), transcranial Doppler for venous drainage (CPT 93886 when billed for CCSVI), and transluminal balloon angioplasty (CPT 35476) used for venous dilation in MS—sometimes called CCSVI treatment—are not covered.

If you're billing virtual reality-assisted therapy (add-on code +0770T), this code also appears in the non-covered group under this policy. Document carefully if you believe a covered primary service supports it, and talk to your compliance officer before billing it in an MS context on an Aetna commercial plan.

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Coverage Indications at a Glance

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Aetna Multiple Sclerosis Billing Guidelines and Action Items 2026

These are the steps your billing team should complete before submitting MS drug claims under CPB 0264 on any Aetna commercial plan.

Copy Action Items

If your practice handles a high volume of Aetna commercial MS claims across multiple drug types, review this full policy with your compliance officer. The interaction between CPB 0264, the Pharmacy CPBs, and the site-of-care policy creates complexity. A single authorization process that doesn't account for all three can generate systematic claim denial patterns that are hard to unwind.

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CPT, HCPCS, and ICD-10 Codes for Multiple Sclerosis Under CPB 0264

Covered CPT Codes (When Selection Criteria Are Met)

Other CPT Codes Related to CPB 0264 (Infusion Administration)

Not Covered / Experimental CPT Codes

HCPCS Codes Related to CPB 0264

Code	Type	Description Copy
J0881	HCPCS	Injection, darbepoetin alfa, 1 mcg (non-ESRD use)
J0885	HCPCS	Injection, epoetin alfa (for non-ESRD use), 100 units
J0888	HCPCS	Injection, epoetin beta, 1 microgram (for non-ESRD use)

Note: The policy data does not include ICD-10-CM codes in this update. Aetna's clinical criteria for MS are defined by relapse status and prior treatment history, not by diagnosis code alone.

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