TL;DR: Aetna, a CVS Health company, modified CPB 0274 governing hepatic lesion ablation coverage, effective September 26, 2025. Billing teams handling CPT codes 47370, 47380, 47381, 47382, 47383, and related ablation procedures need to review the updated five-part medical necessity criteria before submitting claims.
| Field | Detail |
|---|---|
| Payer | Aetna |
| Policy | Ablation of Hepatic Lesions |
| Policy Code | CPB 0274 Aetna |
| Change Type | Modified |
| Effective Date | 2025-09-26 |
| Impact Level | High |
| Specialties Affected | Interventional Radiology, Hepatobiliary Surgery, Oncology, General Surgery |
| Key Action | Audit all active hepatic ablation cases against the updated five-part selection criteria before billing CPT 47370, 47380, 47381, 47382, or 47383 on or after September 26, 2025 |
Aetna Hepatic Lesion Ablation Coverage Policy: Medical Necessity Requirements 2025
The Aetna hepatic lesion ablation coverage policy under CPB 0274 covers cryosurgery, microwave ablation, and conventional tumor-puncture nonpulsed radiofrequency ablation (RFA) — but only when a specific five-part criteria set is fully satisfied. Every single criterion must be met. Aetna is explicit about that.
The covered diagnoses are narrow. Aetna covers these procedures for members with isolated colorectal cancer liver metastases (C18.0–C20 with C78.7) or hepatocellular carcinoma (C22.0, C22.2–C22.8). Unresectable neuroendocrine tumors metastatic to the liver (C7B.02) are also covered. Outside those diagnoses, you're in experimental territory.
Here's the five-part test Aetna applies — and your documentation needs to address all five explicitly:
| # | Covered Indication |
|---|---|
| 1 | Diagnosis: The member has hepatic metastases from a colorectal primary cancer, or has hepatocellular carcinoma. |
| 2 | Isolated liver disease: No nodal or extra-hepatic systemic metastases. If staging shows disease outside the liver, ablation is not covered. |
| 3 | Complete destruction feasible: Pre-operative imaging must support that all liver tumors can potentially be destroyed by the ablation procedure. |
| 4 | Surgical unresectability: Open surgical resection is Aetna's preferred treatment. The member must be an unacceptable surgical candidate due to tumor location, extent of disease, or comorbidities that prevent tolerating open resection. |
| 5 | Size and parenchymal limits: Lesions must be 4 cm or less in diameter and occupy less than 50% of liver parenchyma. |
That last criterion matters for claim denial prevention. A tumor at 4.2 cm gets this procedure denied. Document the exact measurement from pre-operative imaging in your records. Don't rely on "approximately 4 cm" in the notes.
Aetna also covers a combination approach: conventional tumor-puncture nonpulsed RFA combined with transcatheter arterial chemoembolization (TACE) for unresectable hepatocellular carcinoma. CPT 37243 (vascular embolization) and 75894 (transcatheter therapy, embolization, radiological supervision and interpretation) are relevant here. The same RFA criteria above apply to the combined-modality cases.
Prior authorization requirements for hepatic ablation under Aetna vary by plan. Given the medical necessity complexity and the high reimbursement at stake, confirm prior auth requirements with your specific Aetna plan contract before scheduling. Don't assume outpatient surgical codes skip the auth queue.
Aetna Hepatic Lesion Ablation Exclusions and Non-Covered Indications
Aetna's coverage policy is direct: when the five-part criteria above are not met, cryosurgery, microwave ablation, and RFA of hepatic lesions are considered experimental, investigational, or unproven. That's a hard line.
Several specific technologies are explicitly not covered under CPB 0274. Microwave ablation for hepatic hemangioma falls into the non-covered bucket. No-touch radiofrequency ablation techniques are also not covered. Irreversible electroporation — billed under 0600T and 0601T — is not covered for the indications listed in this policy. Histotripsy using acoustic energy delivery (0686T, 0888T) is not covered either.
Focused ultrasound ablation billed under HCPCS C9734, and histotripsy of malignant renal tissue under C9790, are explicitly excluded. These are not covered for any indication listed in CPB 0274. If your interventional radiology team is billing these codes for hepatic work under Aetna, expect denials.
The policy also calls out the new Category III code 0944T — 3D contour simulation of target liver lesions for image-guided percutaneous microwave ablation. This falls into the non-covered experimental group. If your facility recently added this to your charge capture, flag it for Aetna cases specifically.
Coverage Indications at a Glance
| Indication | Status | Relevant Codes | Notes |
|---|---|---|---|
| Isolated colorectal cancer liver metastases — surgical candidate criteria met | Covered | 47370, 47380, 47381, 47382, 47383; C18.0–C20 + C78.7 | All five selection criteria must be met; lesions ≤4 cm |
| Hepatocellular carcinoma — surgical candidate criteria met | Covered | 47370, 47380, 47381, 47382, 47383; C22.0, C22.2–C22.8 | Isolated liver disease required; no extrahepatic mets |
| Unresectable neuroendocrine tumors metastatic to liver | Covered | 47370, 47380, 47381, 47382, 47383; C7B.02 | RFA, microwave, or cryosurgery covered |
| Unresectable HCC — combination RFA + TACE | Covered | 47382 + 37243 + 75894 | RFA criteria must be met; see also CPB 0268 |
| Hepatic lesion ablation — criteria not met | Not Covered (Experimental) | All ablation CPTs | Any criteria failure = experimental designation |
| Microwave ablation for hepatic hemangioma (D18.03) | Not Covered | 37242 | Explicitly experimental under CPB 0274 |
| Irreversible electroporation | Not Covered | 0600T, 0601T | Not covered for any CPB 0274 indication |
| Histotripsy of hepatic malignant tissue | Not Covered | 0686T, C9790 | Not covered for any CPB 0274 indication |
| 3D contour simulation for microwave ablation | Not Covered | 0944T | Considered experimental |
| Focused ultrasound ablation — non-uterine | Not Covered | C9734 | Not covered for hepatic indications |
Aetna Hepatic Lesion Ablation Billing Guidelines and Action Items 2025
The effective date is September 26, 2025. If you're billing hepatic ablation under Aetna and haven't reviewed your workflows against this update, do it now.
| # | Action Item |
|---|---|
| 1 | Audit your charge capture for CPT 47370, 47380, 47381, 47382, and 47383 before September 26, 2025. Confirm that every case billed to Aetna has documentation supporting all five medical necessity criteria. Missing one criterion is a denial. |
| 2 | Add 0600T, 0601T, 0686T, 0888T, and 0944T to your Aetna denial-watch list. These Category III codes are not covered under CPB 0274. If your facility bills these for hepatic work, create a payer-specific edit that flags Aetna cases for review before claim submission. |
| 3 | Verify tumor size documentation in the procedure notes. The 4 cm threshold is absolute. Pre-operative imaging reports must specify exact tumor diameter. Vague language like "sub-5 cm lesion" is not enough. Your medical director should confirm that operative reports include the specific measurements Aetna's reviewers will look for. |
| 4 | Confirm prior auth requirements for your specific Aetna product lines. Commercial HMO, PPO, and Medicare Advantage plans under Aetna may have different prior authorization requirements. The hepatic ablation billing guidelines under CPB 0274 don't specify a universal auth rule — so check your contract or call provider relations before scheduling. |
| 5 | Flag combination RFA + TACE cases for dual-code review. When billing CPT 47382 alongside 37243 or 75894 for combined RFA and TACE in unresectable HCC, document that the RFA criteria are independently met. Aetna's reviewers will check for that. Also cross-reference CPB 0268 for the TACE components — your billing team should have both policies on hand for these cases. |
| 6 | Remove HCPCS C9734 and C9790 from any Aetna hepatic ablation charge templates. These are not covered for any indication in this policy. Having them in a template increases the risk of accidental claim submission and downstream denials that take time to work. |
| 7 | Talk to your compliance officer if you're billing hepatic hemangioma ablation under Aetna. The policy specifically calls out microwave ablation for hepatic hemangioma (D18.03) as non-covered. If your team has been billing 37242 for this indication under Aetna, review your claims history. Reimbursement received for non-covered services creates a repayment risk. |
| 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 Hepatic Lesion Ablation Under CPB 0274
Covered CPT Codes (When Selection Criteria Are Met)
| Code | Type | Description |
|---|---|---|
| 47370 | CPT | Laparoscopy, surgical, ablation of 1 or more liver tumor(s); radiofrequency |
| 47380 | CPT | Ablation, open, of one or more liver tumor(s); radiofrequency |
| 47381 | CPT | Ablation, open, of one or more liver tumor(s); cryosurgical |
| 47382 | CPT | Ablation, one or more liver tumor(s), percutaneous, radiofrequency |
| 47383 | CPT | Ablation, 1 or more liver tumor(s), percutaneous, cryoablation |
| 37243 | CPT | Vascular embolization or occlusion, inclusive of all radiological supervision and interpretation (covered for combination RFA + TACE indication) |
| 75894 | CPT | Transcatheter therapy, embolization, any method, radiological supervision and interpretation |
Not Covered / Experimental Codes
| Code | Type | Description | Reason |
|---|---|---|---|
| 0600T | CPT | Ablation, irreversible electroporation; 1 or more tumors per organ, including imaging guidance | Not covered — experimental/investigational under CPB 0274 |
| 0601T | CPT | Ablation, irreversible electroporation; 1 or more tumors, including fluoroscopic and ultrasound guidance | Not covered — experimental/investigational under CPB 0274 |
| 0686T | CPT | Histotripsy of malignant hepatocellular tissue via acoustic energy delivery | Not covered — experimental/investigational under CPB 0274 |
| 0888T | CPT | Histotripsy of malignant renal tissue via acoustic energy delivery | Not covered — experimental/investigational under CPB 0274 |
| 0944T | CPT | 3D contour simulation of target liver lesion(s) and margin(s) for image-guided percutaneous microwave ablation | Not covered — experimental/investigational under CPB 0274 |
| 37242 | CPT | Vascular embolization or occlusion (arterial, other than hemorrhage or tumor) | Not covered for hepatic hemangioma indication under CPB 0274 |
| C9734 | HCPCS | Focused ultrasound ablation/therapeutic intervention, other than uterine leiomyomata, with magnetic resonance imaging guidance | Not covered for any indication listed in CPB 0274 |
| C9790 | HCPCS | Histotripsy of malignant renal tissue via acoustic energy delivery | Not covered for any indication listed in CPB 0274 |
Other Related Codes (Monitoring and Guidance)
| Code | Type | Description |
|---|---|---|
| 76940 | CPT | Ultrasound guidance for, and monitoring of, parenchymal tissue ablation |
| 77013 | CPT | Computerized tomography guidance for, and monitoring of, parenchymal tissue ablation |
| 77022 | CPT | Magnetic resonance guidance for, and monitoring of, parenchymal tissue ablation |
| C1886 | HCPCS | Catheter, extravascular tissue ablation, any modality (insertable) |
Key ICD-10-CM Diagnosis Codes
| Code | Description |
|---|---|
| B67.5 | Echinococcus multilocularis infection of liver (hepatic alveolar echinococcosis) |
| C18.0–C20 (with C78.7 also required) | Malignant neoplasm of colon, rectosigmoid junction, and rectum — isolated with liver metastases |
| C22.0 | Hepatocellular carcinoma |
| C22.2–C22.8 | Malignant neoplasm of liver (including hepatoblastoma) |
| C7B.02 | Secondary carcinoid tumors of liver (unresectable with liver metastases) |
| D01.5 | Carcinoma in situ of liver, gallbladder, and bile ducts (hepatocellular cancer) |
| D13.4 | Benign neoplasm of liver |
| D18.03 | Hemangioma of intra-abdominal structures (giant hepatic hemangioma) |
One ICD-10 pairing worth flagging: colorectal primary malignancy codes (C18.0–C20) require C78.7 as a secondary code to establish liver metastases. Submitting the primary colorectal code alone, without C78.7, will not satisfy Aetna's diagnosis criteria for this policy. Build that pairing into your charge capture as a required code set.
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