Breast Biopsy Procedures — CPB 0269 | AETNA Coverage Update

Aetna modified CPB 0269 for breast biopsy procedures, effective September 26, 2025. Here's what changes for billing teams.

Aetna, a CVS Health company, updated CPB 0269 to formally recognize digital breast tomosynthesis (DBT)-guided biopsy as an equally acceptable alternative to standard mammographically guided biopsy. This affects CPT codes 19081–19086, 19281–19288, 76942, 77061–77063, HCPCS codes C7501, C7502, and G0279, among dozens of others tied to minimally invasive image-guided breast biopsy. If your practice bills Aetna for breast biopsy procedures in 2025, audit your charge capture now.

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Quick-Reference Table

Field	Detail Copy
Payer	Aetna, a CVS Health company
Policy	Breast Biopsy Procedures
Policy Code	CPB 0269 Aetna
Change Type	Modified
Effective Date	September 26, 2025
Impact Level	Medium — expands covered alternatives; adds explicit DBT-guidance equivalence
Specialties Affected	Breast surgery, radiology, surgical oncology, women's health
Key Action	Update charge capture to include DBT-guided biopsy codes (CPT 77061–77063, G0279) and confirm documentation meets Aetna medical necessity criteria before billing

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Aetna Breast Biopsy Coverage Criteria and Medical Necessity Requirements 2025

The core of this coverage policy is straightforward: Aetna covers minimally invasive image-guided breast biopsy procedures as alternatives to needle localization core surgical biopsy (NLBx). The key phrase is "alternatives to NLBx." Medical necessity depends on the lesion being non-palpable or difficult to palpate.

Aetna defines "difficult to palpate" in specific, billable terms. The lesion must be deep, mobile, small (under 2 cm), or composed of clustered microcalcifications. Document one of these characteristics in every chart before you submit a claim for CPT 19081–19086 or 19281–19288. Missing documentation is the fastest path to a claim denial.

Six biopsy approaches meet Aetna's medical necessity standard under this policy:

The new addition is explicit: digital breast tomosynthesis-guided biopsy is now an equally acceptable alternative to mammographically guided biopsy for all medically necessary indications. Bill DBT guidance using CPT 77061, 77062, 77063, or HCPCS G0279. This is not an experimental or conditional approval — Aetna treats it as equivalent.

If your facility performs DBT-guided biopsies and you've been under-billing or skipping the guidance code out of uncertainty, this coverage policy change removes that ambiguity. Bill it.

Prior authorization requirements for breast biopsy billing under Aetna vary by plan. Check the member's specific plan before scheduling. Not every Aetna product follows CPB 0269 identically — self-funded plans can carve out coverage. Confirm prior auth requirements at time of scheduling, not at time of billing.

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Aetna Breast Biopsy Exclusions and Non-Covered Indications

Several CPT codes in this policy carry explicit non-coverage designations for specific technologies. Know these before you build your charge capture.

SAVI SCOUT Surgical Guidance System: Aetna does not cover CPT 19120, 19121, 19122, 19123, 19124, 19125, 19126, 19301, or 19302 when billed for the SAVI SCOUT system. These excision codes are listed in the policy but are flagged as not covered for that specific indication. Submitting them for SAVI SCOUT cases will result in denial.

Pegulicianine (HCPCS A9615): CPT 19301 and 19302 (partial mastectomy) are also not covered when tied to pegulicianine use. Pegulicianine is billed as A9615, and Aetna excludes it from covered indications under this policy.

Category III codes 0546T and 0945T: These codes — radiofrequency spectroscopy for intraoperative margin assessment (0546T) and intraoperative assessment for abnormal tissue (0945T) — are listed under the tomosynthesis-guided radiofrequency identification group. Verify payer-specific coverage before submitting. Category III codes carry higher denial risk across all payers, and Aetna's CPB 0269 does not explicitly list them as covered.

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Coverage Indications at a Glance

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Aetna Breast Biopsy Billing Guidelines and Action Items 2025

The effective date of September 26, 2025 is already past. If you haven't updated your workflows yet, do it now.

Copy Action Items

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CPT, HCPCS, and ICD-10 Codes for Breast Biopsy Under CPB 0269

Covered CPT Codes (When Selection Criteria Are Met)

Covered HCPCS Codes (When Selection Criteria Are Met)

Code	Description Copy
C7501	Percutaneous breast biopsies using stereotactic guidance, with placement of breast localization device(s)
C7502	Percutaneous breast biopsies using magnetic resonance guidance, with placement of breast localization device(s)
G0279	Diagnostic digital breast tomosynthesis, unilateral or bilateral

HCPCS Code — Not Covered Under This Policy

Code	Description	Notes Copy
A9615	Injection, pegulicianine, 1 mg	Excluded; associated with non-covered SAVI SCOUT/pegulicianine indications

Key ICD-10-CM Diagnosis Codes

Note: The full ICD-10-CM list under CPB 0269 contains 259 codes. The codes above represent the primary diagnostic categories. Pull the full list from the source policy before building your charge capture edits.

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