Spasticity Management — CPB 0362 | AETNA Coverage Update

TL;DR: Aetna, a CVS Health company, modified CPB 0362 governing spasticity management, effective February 25, 2026. This coverage policy update expands the list of procedures Aetna deems experimental or investigational — while maintaining surgical coverage for refractory spasticity under strict medical necessity criteria. If your team bills CPT 63185, 63190, 64600–64640, or 64708–64714 for spasticity procedures, here's what changes.

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Quick-Reference Table

Field	Detail Copy
Payer	Aetna, a CVS Health company
Policy	Spasticity Management
Policy Code	CPB 0362
Change Type	Modified
Effective Date	February 25, 2026
Impact Level	High
Specialties Affected	Neurosurgery, neurology, physical medicine & rehabilitation, pain management, pediatrics
Key Action	Audit active spasticity claims against the three-part medical necessity criteria before billing CPT 63170, 63185, 63190, 64600–64640, or 64708–64714

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Aetna Spasticity Management Coverage Criteria and Medical Necessity Requirements 2026

The Aetna spasticity management coverage policy under CPB 0362 Aetna system is a gatekeeper policy. Surgical procedures aren't automatically covered — every claim needs to clear a three-part test before Aetna considers them medically necessary.

Here are the three criteria. Every one must be met:

#	Covered Indication Copy
1	The member has good intrinsic lower extremity motor power but is limited in ambulation by spasticity.
2	The member has the functional capacity and motivation to participate in post-operative rehabilitation.
3	The member has tried and failed non-surgical medical management — specifically baclofen or other muscle relaxants.

That third criterion is the one your team will fight about most. "Failed conservative management" needs documentation. Vague chart notes about prior therapy won't clear medical necessity review. You need dates, dosages, duration, and documented failure in the record before you bill CPT 63170 (laminectomy with myelotomy), CPT 63185 or 63190 (laminectomy with rhizotomy), or CPT 63600 (stereotactic spinal cord lesion).

When all three criteria are met, Aetna covers five surgical procedures:

Spasticity management billing for selective posterior rhizotomy has an additional layer. Aetna considers it experimental — not medically necessary — when the member has any of five contraindications. We cover those in the next section.

Prior authorization requirements aren't explicitly detailed in CPB 0362 itself, but neurosurgical procedures at this level virtually always trigger prior auth under Aetna commercial plans. Check your specific plan benefit document. Don't submit claims for CPT 63185 or 63600 without confirming auth status first — a missed PA step is the fastest path to a claim denial on these high-dollar procedures.

The reimbursement exposure here is significant. These are complex surgical procedures. Getting the medical necessity documentation wrong doesn't just affect one claim — it can trigger retrospective audits across your entire spasticity case mix.

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Aetna Spasticity Management Exclusions and Non-Covered Indications

This is where CPB 0362 gets detailed — and where most billing teams will face denials if they're not paying attention.

Aetna has designated 20+ specific procedures as experimental, investigational, or unproven for spasticity management. This isn't a catch-all exclusion. Each line item is a specific clinical modality with a specific diagnosis pairing. That matters for billing because many of these procedures have CPT codes that are otherwise billable in other contexts.

Selective posterior rhizotomy contraindications: Aetna flips this procedure from covered to experimental when the member has any of the following:

Members ages 2 to 6 are optimal candidates for selective posterior rhizotomy. Outside that window — or with any contraindication present — document carefully before billing.

Procedures designated experimental across all spasticity indications:

The policy explicitly calls out acupuncture (including electro-acupuncture) for post-stroke spasticity. It also excludes dry needling (CPT 20560, 20561) for post-stroke spasticity. These are codes your physical medicine or integrative medicine teams may bill regularly — but not for this indication against Aetna.

Chemo-denervation with alcohol or phenol (CPT 64642–64645) for limb spasticity following spinal cord injury is experimental under this policy. Note the specificity: this exclusion applies to spinal cord injury. Botulinum toxin chemodenervation for other indications isn't addressed the same way — this is a targeted exclusion by mechanism and diagnosis.

Electrical stimulation as an adjunct to botulinum toxin is experimental. If you're billing a combined protocol, the electrical stimulation component won't clear this coverage policy.

Spinal cord stimulation (CPT 63650, 63655, 63661–63664, 63685, 63688) is explicitly non-covered for spasticity. Thalamic stimulation codes (CPT 61863, 61864, 61867, 61868, 61880, 61885, 61886, 61888) are also excluded for spasticity associated with disorders of consciousness following brain damage. These spinal cord stimulator codes get used across multiple diagnoses — make sure your charge capture routes them correctly by indication.

Extracorporeal shock wave therapy (CPT 0101T) is not covered for post-stroke spasticity or spasticity in children with cerebral palsy.

Transcranial magnetic stimulation (CPT 90867) is not covered for spasticity due to multiple sclerosis or other causes.

Cryoneurolysis for spinal cord injury spasticity — experimental. Focal muscle vibration — experimental. Kinesiotaping for lower extremity spasticity — experimental. Pulsed electromagnetic field (PEMF) therapy for cerebral palsy — experimental.

The real issue here is the diagnosis-code pairing. Most of these modality exclusions are diagnosis-specific. A procedure that's covered for one diagnosis can be experimental for another. Your billing guidelines need to reflect that distinction at the ICD-10 level, not just at the CPT level.

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Coverage Indications at a Glance

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Aetna Spasticity Management Billing Guidelines and Action Items 2026

Copy Action Items

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CPT, HCPCS, and ICD-10 Codes for Spasticity Management Under CPB 0362

Covered CPT Codes (When Selection Criteria Are Met)

Not Covered / Experimental CPT Codes

Note: The policy data includes 9 additional CPT codes not fully detailed in the source data extract. Review the full CPB 0362 at app.payerpolicy.org/p/aetna/0362 for the complete code list.

Note: The policy data includes 37 HCPCS codes and 642 ICD-10-CM codes under this policy. The full code sets are available in the PayerPolicy platform with filtering by coverage group.

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