Aetna modified CPB 0285 for plasmapheresis, plasma exchange, and therapeutic apheresis, effective January 5, 2026. Here's what billing teams need to know.
Aetna, a CVS Health company, updated its plasmapheresis coverage policy under CPB 0285. The primary procedure codes affected are CPT 36511, 36512, and 36514, with CPT 0342T explicitly designated as non-covered. Review the full updated policy at app.payerpolicy.org/p/aetna/0285 to identify specific changes from the prior version. If your team bills therapeutic apheresis for any Aetna commercial plan, this update changes how you document medical necessity and which ICD-10 codes will survive claim review.
Quick-Reference Table
| Field | Detail |
|---|---|
| Payer | Aetna, a CVS Health company |
| Policy | Plasmapheresis/Plasma Exchange/Therapeutic Apheresis |
| Policy Code | CPB 0285 |
| Change Type | Modified |
| Effective Date | January 5, 2026 |
| Impact Level | High |
| Specialties Affected | Hematology, nephrology, neurology, rheumatology, oncology, apheresis centers, hospital outpatient |
| Key Action | Audit active Aetna prior authorizations for apheresis and confirm documentation matches the updated indication-specific criteria before billing CPT 36511, 36512, or 36514 |
Aetna Plasmapheresis Coverage Criteria and Medical Necessity Requirements 2026
The Aetna plasmapheresis coverage policy under CPB 0285 uses a strict indication-by-indication framework. Aetna does not cover therapeutic apheresis as a general category. Each claim must match one of the specific covered diagnoses—and in most cases, must also show that prior treatments failed.
Medical necessity is established only when the clinical scenario meets Aetna's documented criteria. "Failed conventional therapy" is not optional language in this policy. For most indications, it is a hard coverage requirement. Your documentation must prove it, not just assert it.
A few indications have numeric thresholds that Aetna will audit against lab values. For hypertriglyceridemia-induced acute pancreatitis, for example, all three of the following must be true:
| # | Covered Indication |
|---|---|
| 1 | Serum triglyceride level above 1,000 mg/dL |
| 2 | Lipase greater than three times the upper limit of normal (CPT 83690 is a related code) |
| 3 | The patient has hypocalcemia, lactic acidosis, or signs of worsening systemic inflammation or organ dysfunction and/or multi-organ failure |
Bill CPT 36514 for plasma pheresis in that setting. Without all three criteria documented in the chart, Aetna has a clean basis for claim denial.
For essential thrombocythemia (ICD-10 D47.3), platelet pheresis is covered only when the platelet count exceeds 1,000,000/mm³. For leukemia and mantle cell lymphoma (ICD-10 C91.00–C95.92, C83.10–C83.19), leukapheresis via CPT 36511 is covered for acute debulking only—and only when white blood cell count is above 100,000/µL.
For babesiosis (ICD-10 B60.0–B60.9), red blood cell exchange via CPT 36512 is covered when the member has high-grade parasitemia (≥10%), severe anemia (hemoglobin ≤10 g/dL), or hepatic, pulmonary, or renal compromise. The parasitemia percentage or the specific organ system affected must appear in the clinical documentation—not just the babesiosis diagnosis code.
Chronic inflammatory demyelinating polyneuropathy (CIDP) is covered under CPT 36514, but the diagnosis must be documented specifically. Aetna requires symmetric or focal neurological deficits, a slowly progressive or relapsing course lasting two or more months, and characteristic neurophysiological abnormalities. Failing to document all three elements is a common reason for denial on CIDP apheresis claims.
CPB 0285 does not specify prior authorization requirements. PA requirements vary by plan and market. Check your specific Aetna plan contract or the plan's administrative guidelines to confirm what's required before scheduling services.
Aetna Plasmapheresis Exclusions and Non-Covered Indications
CPT 0342T—therapeutic apheresis with selective HDL delipidation and plasma reinfusion—is explicitly not covered under CPB 0285. If your center offers this service, do not bill it to Aetna expecting reimbursement. It is designated as non-covered for all indications listed in the bulletin.
HCPCS code 83695 (lipoprotein (a)) is also classified as not covered for the indications in this bulletin. Do not bundle this into an apheresis claim as a supporting lab code.
The policy also reserves several indications as "last resort" treatments. This language matters for billing. For acute disseminated encephalomyelitis, life-threatening rheumatoid vasculitis, and life-threatening systemic lupus erythematosus, coverage requires documented failure of conventional therapy—including corticosteroids. "Last resort" is not a soft qualifier. Aetna will look for proof that prior treatments failed before approving or paying these claims.
Coverage Indications at a Glance
| Indication | Status | Key CPT Code | Notes |
|---|---|---|---|
| Acute humoral rejection of renal transplants | Covered | 36514 | Medical necessity criteria apply |
| MS with severe neurological deficits, poor response to glucocorticoids | Covered | 36514 | Must fail high-dose glucocorticoids first |
| ANCA-associated vasculitis (Wegener's, microscopic polyangiitis, Churg-Strauss) | Covered | 36514 | Must be unresponsive to conventional therapy |
| Babesiosis with high-grade parasitemia ≥10%, severe anemia (hemoglobin ≤10 g/dL), or hepatic, pulmonary, or renal compromise | Covered | 36512 | Red blood cell exchange; document specific qualifying criterion |
| Catastrophic antiphospholipid syndrome | Covered | 36514 | Widespread thromboembolic disease and visceral damage required |
| CIDP with severe/life-threatening symptoms | Covered | 36514 | Must fail conventional therapy; strict diagnostic documentation required |
| Essential thrombocythemia | Covered | 36514 | Platelet count must exceed 1,000,000/mm³ (platelet pheresis) |
| Goodpasture's syndrome / anti-GBM glomerulonephritis | Covered | 36514 | Advancing renal failure or pulmonary hemorrhage required |
| HELLP syndrome of pregnancy | Covered | 36514 | Thrombocytopenia, hemolysis, or renal failure must worsen 48–72 hrs postpartum |
| Hemolytic uremic syndrome | Covered | 36514 | Medical necessity criteria apply |
| Hyperglobulinemias (multiple myeloma, cryoglobulinemia, hyperviscosity) | Covered | 36514 | Includes Waldenström macroglobulinemia |
| Hypertriglyceridemia-induced acute pancreatitis | Covered | 36514 | All three numeric criteria must be met (TG >1,000, lipase >3x ULN, plus hypocalcemia, lactic acidosis, or worsening systemic inflammation or organ dysfunction and/or multi-organ failure) |
| Immune checkpoint inhibitor-related toxicities | Covered | 36514 | Must fail high-dose steroids first |
| Acute disseminated encephalomyelitis | Covered — last resort | 36514 | Corticosteroids must have failed; severe neurological deficits must persist |
| Life-threatening rheumatoid vasculitis | Covered — last resort | 36514 | Last resort only; conventional therapy must have failed |
| Life-threatening SLE | Covered — last resort | 36514 | Last resort only; clinical deterioration despite conventional therapy |
| Leukemia / mantle cell lymphoma (leukapheresis) | Covered | 36511 | Acute debulking only; WBC >100,000/µL required |
| Myasthenia gravis (selected scenarios) | Covered | 36514 | Four qualifying sub-criteria; impending respiratory crisis, pre-surgical, chronic failure of all other treatments, or natalizumab-associated PML |
| Neuromyelitis optica spectrum disorder | Covered | 36514 | Refractory to glucocorticoids |
| HDL delipidation/plasma reinfusion | Not Covered | 0342T | Explicitly excluded; do not bill to Aetna |
| Lipoprotein (a) testing | Not Covered | 83695 (HCPCS) | Not covered for indications in this CPB |
Aetna Therapeutic Apheresis Billing Guidelines and Action Items 2026
The real issue with therapeutic apheresis billing is documentation timing. Most denials happen not because the indication is wrong, but because the chart doesn't prove the criteria at the time of service. Here's what to do before January 5, 2026 and as you process claims under the updated policy.
| # | Action Item |
|---|---|
| 1 | Audit active prior authorizations for CPT 36511, 36512, and 36514. For any Aetna patient currently on a therapeutic apheresis schedule, confirm the auth was issued under criteria that still apply under the updated CPB 0285. If the auth is old, request revalidation. |
| 2 | Update your intake documentation templates to capture threshold lab values. For hypertriglyceridemia (triglycerides, lipase), essential thrombocythemia (platelet count), leukemia (WBC count), and babesiosis (parasitemia %, hemoglobin, and organ system affected), the policy requires specific numeric thresholds. Your documentation must include the actual lab values—not just the diagnosis. |
| 3 | Flag "last resort" indications in your pre-auth workflow. For SLE, rheumatoid vasculitis, and acute disseminated encephalomyelitis, build a checklist that captures which conventional treatments were tried, when, and what the response was. Aetna will ask. Have the answer before the claim goes out. |
| 4 | Remove CPT 0342T from your Aetna charge capture entirely. This code is non-covered under CPB 0285 for all listed indications. If your charge capture system routes it to Aetna, you will get a denial. Take it off the Aetna fee schedule in your billing system now. |
| 5 | Confirm ICD-10 codes map to the specific sub-criteria. With 438 ICD-10-CM codes in scope, the risk is using a valid code for a diagnosis that doesn't meet Aetna's coverage threshold for that diagnosis. For example, B60.0–B60.9 covers babesiosis—but coverage requires parasitemia ≥10%, severe anemia (hemoglobin ≤10 g/dL), or hepatic, pulmonary, or renal compromise. The ICD-10 code alone won't tell Aetna that. Your clinical notes must. |
| 6 | Talk to your compliance officer if you bill for multiple covered indications under the same session. Combination apheresis scenarios—for example, a patient with both CIDP and an overlapping autoimmune condition—have documentation complexity that goes beyond standard billing guidelines. Get a second set of eyes before submitting. |
| 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 Plasmapheresis Under CPB 0285
Covered CPT Codes (When Selection Criteria Are Met)
| Code | Type | Description |
|---|---|---|
| 36511 | CPT | Therapeutic apheresis: for white blood cells (acute debulking only) |
| 36512 | CPT | Therapeutic apheresis: for red blood cells |
| 36514 | CPT | Therapeutic apheresis: for plasma pheresis |
Not Covered Codes
| Code | Type | Description | Reason |
|---|---|---|---|
| 0342T | CPT | Therapeutic apheresis with selective HDL delipidation and plasma reinfusion | Not covered for indications listed in CPB 0285 |
| 83695 | HCPCS | Lipoprotein (a) | Not covered for indications listed in CPB 0285 |
Key ICD-10-CM Diagnosis Codes
| Code | Description |
|---|---|
| A40.0–A41.9 | Streptococcal and other sepsis |
| A81.2 | Progressive multifocal leukoencephalopathy (natalizumab-associated) |
| B60.0–B60.9 | Babesiosis (high-grade parasitemia ≥10% required) |
| C83.10–C83.19 | Mantle cell lymphoma |
| C88.0–C88.1 | Waldenström macroglobulinemia |
| C90.0–C90.2 | Multiple myeloma |
| C90.10–C90.12 | Plasma cell leukemia |
| C91.00–C95.92 | Lymphoid, myeloid, monocytic, and other leukemias |
| D47.2 | Monoclonal gammopathy (MGUS) |
| D47.3 | Essential (hemorrhagic) thrombocythemia |
| D57.00–D57.819 | Sickle-cell disorders |
| D58.2 | Other hemoglobinopathies |
| D59.0–D59.14 | Autoimmune hemolytic anemias |
The full policy references 438 ICD-10-CM codes. The codes above represent the primary covered diagnosis categories. Review the full CPB 0285 at app.payerpolicy.org/p/aetna/0285 for the complete list before finalizing your billing workflows.
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