Aetna modified CPB 0368 covering hypertensive disorders of pregnancy, effective September 26, 2025. Here's what billing teams need to know about the non-covered designations for CPT 0390U and HCPCS S9211, S9212, and S9213.
Aetna, a CVS Health company, updated Clinical Policy Bulletin 0368, which governs the Aetna hypertensive disorders of pregnancy coverage policy. This modification explicitly designates CPT 0390U (a proprietary lab test for preeclampsia risk using KDR and ENG biomarkers) and HCPCS codes S9211, S9212, and S9213 (home management programs for gestational hypertension, postpartum hypertension, and preeclampsia) as not covered for the indications listed in the policy. The update spans 79 ICD-10-CM diagnosis codes across the O10–O16 range. If your practice or billing team submits claims under any of these codes for Aetna patients, this policy change directly affects your reimbursement.
Quick-Reference Table
| Field | Detail |
|---|---|
| Payer | Aetna (Aetna, a CVS Health company) |
| Policy | Hypertensive Disorders of Pregnancy |
| Policy Code | CPB 0368 |
| Change Type | Modified |
| Effective Date | September 26, 2025 |
| Impact Level | High |
| Specialties Affected | OB/GYN, Maternal-Fetal Medicine, Home Health, Clinical Lab |
| Key Action | Remove CPT 0390U and HCPCS S9211–S9213 from charge capture for Aetna patients and expect denials on these codes effective September 26, 2025 |
Aetna Hypertensive Disorders of Pregnancy Coverage Criteria and Medical Necessity Requirements 2025
CPB 0368 Aetna covers management and treatment of hypertensive disorders of pregnancy under standard medical necessity criteria. The policy addresses a wide spectrum of conditions — pre-existing hypertension complicating pregnancy (O10 codes), superimposed preeclampsia (O11 codes), gestational hypertension (O13 codes), preeclampsia and severe preeclampsia (O14 codes), eclampsia (O15 codes), and unspecified maternal hypertension (O16 codes).
The core issue here is what the policy explicitly excludes. Aetna does not cover CPT 0390U for preeclampsia risk stratification. CPT 0390U is a proprietary lab analysis — specifically, it measures kinase insert domain receptor (KDR) and endoglin (ENG) alongside retinol-binding protein — marketed as a predictive tool for preeclampsia. Aetna's position is that this test does not meet medical necessity criteria for the indications listed in CPB 0368.
Similarly, HCPCS S9211, S9212, and S9213 for home management programs covering gestational hypertension, postpartum hypertension, and preeclampsia are all designated as not covered. These are bundled home health programs that include administrative services and professional pharmacy services. Aetna is drawing a clear line: it does not recognize these home management programs as meeting medical necessity under this coverage policy.
Prior authorization requirements for other services under this policy are not specified in this modification. That means your prior authorization workflows for covered obstetric management services are unlikely to change from this update alone. But the non-covered designations for 0390U and the S92xx codes are firm — prior auth won't save these claims because the denial basis is coverage status, not authorization.
Aetna Hypertensive Disorders of Pregnancy Exclusions and Non-Covered Indications
This is the heart of the change. Four codes are now explicitly listed as not covered for indications in CPB 0368.
CPT 0390U is the preeclampsia biomarker test. If your lab or clinical team has been ordering this test for Aetna patients with preeclampsia risk or diagnosis, those claims will deny. This mirrors a pattern seen with other proprietary lab tests (PLTs) — Aetna routinely scrutinizes them under medical necessity standards before granting coverage. The real issue here is that many practices have billed 0390U under the assumption it would be covered once the ICD-10 code matched a relevant obstetric diagnosis. That assumption is wrong for Aetna patients under CPB 0368.
HCPCS S9211 (home management of gestational hypertension), S9212 (home management of postpartum hypertension), and S9213 (home management of preeclampsia) are all excluded. These S-codes are not part of standard Medicare billing — they're primarily used by commercial payers and managed care plans. Aetna is explicitly rejecting reimbursement for these bundled home management programs.
If you've been billing S9213 for high-risk preeclampsia patients managed at home, expect those claims to come back as claim denials effective September 26, 2025. This is not ambiguous. The policy lists them directly under "not covered for indications listed in the CPB."
Coverage Indications at a Glance
| Indication | Status | Relevant Codes | Notes |
|---|---|---|---|
| Preeclampsia biomarker testing (KDR, ENG, retinol-binding protein) | Not Covered | CPT 0390U | Proprietary lab test; does not meet Aetna medical necessity criteria under CPB 0368 |
| Home management of gestational hypertension | Not Covered | HCPCS S9211 | Bundled home program not covered for indications in this CPB |
| Home management of postpartum hypertension | Not Covered | HCPCS S9212 | Bundled home program not covered for indications in this CPB |
| Home management of preeclampsia | Not Covered | HCPCS S9213 | Bundled home program not covered for indications in this CPB |
| Pre-existing hypertension complicating pregnancy, childbirth, puerperium | Policy-governed | O10.x series | Coverage subject to standard medical necessity; no specific exclusion in this update |
| Superimposed preeclampsia | Policy-governed | O11.x series | Coverage subject to standard medical necessity; no specific exclusion in this update |
| Gestational hypertension without significant proteinuria | Policy-governed | O13.x series | Coverage subject to standard medical necessity; S9211 not covered |
| Preeclampsia with significant proteinuria / Severe preeclampsia | Policy-governed | O14.x series | Coverage subject to standard medical necessity; S9213 not covered |
| Eclampsia in pregnancy | Policy-governed | O15.x series | Coverage subject to standard medical necessity |
| Unspecified maternal hypertension | Policy-governed | O16.x series | Coverage subject to standard medical necessity |
Aetna Hypertensive Disorders of Pregnancy Billing Guidelines and Action Items 2025
The effective date of September 26, 2025 has already passed. That means if your billing team hasn't acted on this yet, you have live exposure right now. Here's what to do.
| # | Action Item |
|---|---|
| 1 | Pull claims billed on or after September 26, 2025 that include CPT 0390U for Aetna patients. If any are outstanding or have been paid, audit them immediately. Aetna can recoup payments on claims that don't meet the coverage policy criteria. |
| 2 | Remove CPT 0390U from your Aetna charge capture for obstetric patients. If your OB or MFM providers routinely order preeclampsia biomarker testing, notify them that hypertensive disorders of pregnancy billing under Aetna no longer supports 0390U for these indications. |
| 3 | Remove HCPCS S9211, S9212, and S9213 from any Aetna fee schedule or charge master entries used for home management programs. These codes will not be reimbursed. Billing them wastes submission cycles and generates claim denial volume that creates audit flags. |
| 4 | Coordinate with your home health billing team. If a separate agency handles the home management programs for your high-risk OB patients, alert them to this Aetna coverage policy change immediately. They may not track CPB modifications directly and could be submitting S-codes without knowing they're now explicitly excluded. |
| 5 | Document clinical rationale for alternative approaches. If your clinical team genuinely believes preeclampsia biomarker testing or home monitoring programs are medically necessary for an Aetna patient, that's an appeal situation — not a billing workaround. Work with your compliance officer to understand whether an appeal based on medical necessity is viable, and gather clinical documentation before submitting. |
| 6 | Check your other payer policies for the same codes. Aetna's exclusion of 0390U and the S92xx series doesn't mean every payer follows. But this change is worth cross-referencing against your Cigna Healthcare, UnitedHealthcare, and BCBS policies for the same codes. One payer's exclusion often signals a broader trend. |
If you're managing a high volume of Aetna OB patients and you're unsure how this change affects your revenue cycle mix, talk to your compliance officer before submitting another round of claims with these codes.
| 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 Hypertensive Disorders of Pregnancy Under CPB 0368
Not Covered CPT Codes
| Code | Type | Description | Reason |
|---|---|---|---|
| 0390U | CPT | Obstetrics (preeclampsia), kinase insert domain receptor (KDR), Endoglin (ENG), and retinol-binding protein analysis | Not covered for indications listed in CPB 0368 |
Not Covered HCPCS Codes
| Code | Type | Description | Reason |
|---|---|---|---|
| S9211 | HCPCS | Home management of gestational hypertension, includes administrative services, professional pharmacy services | Not covered for indications listed in CPB 0368 |
| S9212 | HCPCS | Home management of postpartum hypertension, includes administrative services, professional pharmacy services | Not covered for indications listed in CPB 0368 |
| S9213 | HCPCS | Home management of preeclampsia, includes administrative services, professional pharmacy services | Not covered for indications listed in CPB 0368 |
Key ICD-10-CM Diagnosis Codes
These are the diagnosis codes governing the scope of CPB 0368. All 79 codes fall within the O10–O16 range.
| Code | Description |
|---|---|
| O10.011–O10.019 | Hypertensive heart disease complicating pregnancy, childbirth, and the puerperium |
| O10.911–O10.919 | Hypertension complicating pregnancy, childbirth, and the puerperium |
| O10.111–O10.119 | Other pre-existing hypertension complicating pregnancy, childbirth, and the puerperium |
| O10.211–O10.219 | Other pre-existing hypertension complicating pregnancy, childbirth, and the puerperium |
| O10.311–O10.319 | Other pre-existing hypertension complicating pregnancy, childbirth, and the puerperium |
| O10.411–O10.419 | Hypertension secondary, complicating pregnancy, childbirth, and the puerperium |
| O11.1–O11.9 | Pre-existing hypertension with superimposed preeclampsia, complicating pregnancy, childbirth, and the puerperium |
| O13.1–O13.9 | Gestational (pregnancy-induced) hypertension without significant proteinuria |
| O14.00–O14.03 | Mild to moderate preeclampsia |
| O14.90–O14.95 | Gestational hypertension with significant proteinuria, unspecified |
| O14.10–O14.13 | Severe preeclampsia |
| O15.0–O15.9 | Eclampsia in pregnancy |
| O16.1–O16.6 | Unspecified maternal hypertension |
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