Aetna modified CPB 0293 covering amniotic membrane transplantation and limbal stem cell transplantation for ocular surface reconstruction, effective September 26, 2025. Here's what changes for billing teams.
Aetna, a CVS Health company, updated CPB 0293 to clarify medical necessity criteria for ocular surface procedures billed under CPT codes 65778, 65779, 65780, 65781, and 65782. The policy governs coverage for corneal graft procedures, amniotic membrane transplantation, limbal stem cell transplantation, corneal stromal lenticule transplantation, and sural nerve grafting for ocular indications. If your practice bills Aetna for any of these procedures, this coverage policy change requires action before you submit another claim.
Quick-Reference Table
| Field | Detail |
|---|---|
| Payer | Aetna, a CVS Health company |
| Policy | Corneal Graft and Amniotic Membrane Transplantation, Corneal Stromal Lenticule Transplantation, Limbal Stem Cell Transplantation, or Sural Nerve Grafting for Ocular Indications |
| Policy Code | CPB 0293 |
| Change Type | Modified |
| Effective Date | September 26, 2025 |
| Impact Level | High |
| Specialties Affected | Ophthalmology, Corneal Surgery, Ocular Oncology |
| Key Action | Audit active Aetna claims for CPT 65778–65782 and V2790 against updated medical necessity criteria before submitting new claims |
Aetna Amniotic Membrane and Limbal Stem Cell Transplantation Coverage Criteria and Medical Necessity Requirements 2025
The core coverage rule under CPB 0293 Aetna is this: preserved human amniotic membrane transplantation and limbal stem cell transplantation are medically necessary for ocular surface reconstruction in members with limbal deficiency—meaning hypofunction or total loss of limbal stem cells—that is refractory to conventional treatment.
"Refractory to conventional treatment" is doing a lot of work in that sentence. You need documented evidence that standard therapies failed before Aetna will consider these procedures medically necessary. That documentation belongs in the chart, in the prior authorization request, and on the claim.
The qualifying conditions that satisfy the "any of the following" threshold are anchored to the ICD-10-CM codes listed in the policy—659 of them, spanning herpesviral keratitis (B00.52), zoster keratitis (B02.33), Acanthamoeba keratoconjunctivitis (B60.13), conjunctival malignancies (C69.00–C69.02), corneal malignancies (C69.11), corneal dermoids (D31.10–D31.12), and a broad sweep of diabetic eye disease codes across the E08, E09, and E10 series. That ICD-10 list is not decorative—Aetna uses it to gate coverage decisions.
If your diagnosis code isn't on the covered list, you face a high risk of claim denial before anyone looks at the clinical documentation. Map your diagnosis codes to the policy list before you bill.
Prior authorization is the practical reality here. Procedures like CPT 65781 (limbal stem cell allograft) and CPT 65782 (limbal conjunctival autograft) carry enough clinical and financial weight that prior auth requests without strong documentation of limbal deficiency and failed conventional treatment will come back denied. Build your prior auth packets around the specific eligibility criteria in CPB 0293.
Amniotic membrane placement under CPT 65778 (without sutures) and CPT 65779 (single layer, sutured) follows the same medical necessity logic. So does CPT 65780 (multiple-layer amniotic membrane transplantation) with one notable exception discussed below. HCPCS V2790 covers the amniotic membrane itself as a supply—bill it alongside the applicable procedure code.
Reimbursement for these procedures depends entirely on meeting selection criteria. Aetna does not cover these codes for experimental or off-label indications, and the distinction matters for your revenue cycle.
Aetna Amniotic Membrane Transplantation Exclusions and Non-Covered Indications
Two codes in CPB 0293 carry explicit non-covered status, and your charge capture needs to reflect that.
CPT 65780 (ocular surface reconstruction via multiple-layer amniotic membrane transplantation) is listed in the covered group but carries a notation that it is not covered for certain indications. The policy data flags this code with a caveat—review the full CPB 0293 text to confirm which specific indications trigger the exclusion. Don't assume the multiple-layer code is covered just because the single-layer codes are.
HCPCS Q4155 (Neoxflo or Clarixflo, 1 mg) is not covered for indications listed in CPB 0293. Full stop. If your practice uses these products in conjunction with ocular surface reconstruction, do not bill Q4155 and expect Aetna reimbursement. This is a straightforward non-covered code under this policy—billing it creates an unnecessary claim denial and a write-off.
This is the kind of code-level detail that gets missed when billing teams rely on general ophthalmic charge masters without cross-referencing individual payer policies. One Q4155 on an Aetna claim will trigger a denial for that line item. Multiple claims with Q4155 can flag your practice for a broader audit.
Coverage Indications at a Glance
| Indication | Status | Relevant Codes | Notes |
|---|---|---|---|
| Limbal deficiency (hypofunction or total loss) refractory to conventional treatment | Covered | CPT 65778, 65779, 65780, 65781, 65782; HCPCS V2790 | Must document failed conventional treatment; prior auth strongly recommended |
| Herpesviral keratitis / ocular herpes | Covered (if limbal deficiency criteria met) | B00.50, B00.52, B00.59, B00.9 | Diagnosis code must appear on policy list |
| Zoster keratitis | Covered (if limbal deficiency criteria met) | B02.33 | Document refractory status |
| Acanthamoeba keratoconjunctivitis | Covered (if limbal deficiency criteria met) | B60.13 | Rare diagnosis—expect heightened scrutiny |
| Conjunctival malignancy | Covered (if limbal deficiency criteria met) | C69.00, C69.01, C69.02 | Ocular oncology cases; document reconstruction necessity |
| Corneal malignancy | Covered (if limbal deficiency criteria met) | C69.11 | Same documentation rules apply |
| Corneal dermoid | Covered (if limbal deficiency criteria met) | D31.10, D31.11, D31.12 | Benign but surgically significant |
| Diabetic eye disease (E08–E10 series, retinal detachment codes) | Covered (if limbal deficiency criteria met) | E08.3521–E10.3549 range | Extensive code list; verify specific code against CPB 0293 before billing |
| Multiple-layer amniotic membrane transplantation for excluded indications | Not Covered | CPT 65780 | Review full CPB 0293 for specific excluded indications |
| Neoxflo or Clarixflo (Q4155) | Not Covered | HCPCS Q4155 | Explicitly excluded for all indications under this CPB |
Aetna Amniotic Membrane Transplantation Billing Guidelines and Action Items 2025
These are the concrete steps your billing team needs to take now that the effective date of September 26, 2025 has passed.
| # | Action Item |
|---|---|
| 1 | Audit your charge master for CPT 65778, 65779, 65780, 65781, 65782, and HCPCS V2790. Confirm that each code links to the correct Aetna coverage criteria in your billing system. If your charge master doesn't flag these codes for Aetna-specific documentation requirements, fix that today. |
| 2 | Remove HCPCS Q4155 from any Aetna claim templates tied to ocular surface reconstruction. This code is not covered under CPB 0293. Any claim submitted with Q4155 for an Aetna member in this procedure category will be denied. Check claims submitted after September 26, 2025 and pull any that included Q4155. |
| 3 | Build a CPB 0293-specific prior authorization checklist. It should require documented limbal deficiency diagnosis, a qualifying ICD-10-CM code from the policy list, and evidence of failed conventional treatment. Your prior auth staff needs this checklist before submitting requests for CPT 65781 or 65782 in particular—those allograft and autograft procedures carry the highest clinical and financial scrutiny. |
| 4 | Cross-reference every Aetna ocular surface claim against the 659-code ICD-10-CM list in CPB 0293. This is tedious but necessary. A diagnosis code that isn't on the list means the claim fails medical necessity review regardless of how strong the clinical documentation is. If your practice management system can run a coverage policy check at charge entry, configure it now. |
| 5 | Flag CPT 65780 claims for supervisor review before submission. The multiple-layer amniotic membrane transplantation code has a partial coverage restriction in CPB 0293. Until your team confirms which specific indications are excluded, treat every 65780 claim as requiring secondary review. The cost of one denied claim is higher than the cost of the review. |
| 6 | Review any Aetna amniotic membrane transplantation billing submitted between September 26, 2025 and today. If claims went out before your team was aware of the modified policy, audit them now. Look specifically for Q4155, for 65780 on potentially excluded indications, and for diagnosis codes not on the CPB 0293 ICD-10 list. |
If your practice has a high volume of Aetna members receiving ocular surface procedures, talk to your compliance officer about a formal post-modification claim review. The ICD-10 list is long enough and the code-level restrictions are specific enough that this warrants a structured audit, not a spot check.
| 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 Amniotic Membrane and Limbal Stem Cell Transplantation Under CPB 0293
Covered CPT Codes (When Selection Criteria Are Met)
| Code | Type | Description |
|---|---|---|
| 65778 | CPT | Placement of amniotic membrane on the ocular surface; without sutures |
| 65779 | CPT | Placement of amniotic membrane on the ocular surface; single layer, sutured |
| 65780 | CPT | Ocular surface reconstruction; amniotic membrane transplantation, multiple layers (not covered for certain indications — review CPB 0293) |
| 65781 | CPT | Ocular surface reconstruction; limbal stem cell allograft (e.g., cadaveric or living donor) |
| 65782 | CPT | Limbal conjunctival autograft (includes obtaining graft) |
Covered HCPCS Codes (When Selection Criteria Are Met)
| Code | Type | Description |
|---|---|---|
| V2790 | HCPCS | Amniotic membrane for surgical reconstruction, per procedure |
Not Covered Codes
| Code | Type | Description | Reason |
|---|---|---|---|
| Q4155 | HCPCS | Neoxflo or Clarixflo, 1 mg | Not covered for indications listed in CPB 0293 |
Key ICD-10-CM Diagnosis Codes
| Code | Description |
|---|---|
| B00.50 | Herpesviral ocular disease, unspecified |
| B00.52 | Herpesviral keratitis |
| B00.59 | Other herpesviral disease of eye |
| B00.9 | Herpesviral infection, unspecified |
| B02.33 | Zoster keratitis |
| B60.13 | Keratoconjunctivitis due to Acanthamoeba |
| C69.00 | Malignant neoplasm of unspecified conjunctiva |
| C69.01 | Malignant neoplasm of right conjunctiva |
| C69.02 | Malignant neoplasm of left conjunctiva |
| C69.11 | Malignant neoplasm of right cornea |
| D31.10 | Benign neoplasm of cornea (dermoid), unspecified |
| D31.11 | Benign neoplasm of right cornea (dermoid) |
| D31.12 | Benign neoplasm of left cornea (dermoid) |
| E08.3521–E08.3549 | Diabetes mellitus due to underlying condition with diabetic retinal detachment (multiple codes) |
| E09.3521–E09.3549 | Drug or chemical-induced diabetes mellitus with diabetic retinal detachment (multiple codes) |
| E10.3521–E10.3549 | Type 1 diabetes mellitus with diabetic retinal detachment (multiple codes) |
The full ICD-10-CM list under CPB 0293 contains 659 codes. The table above reflects the codes explicitly provided in the policy data. Verify your specific diagnosis codes against the complete CPB 0293 document before billing. You can access the full policy at app.payerpolicy.org/p/aetna/0293.
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