Brachytherapy — CPB 0371 | AETNA Coverage Update

Aetna modified CPB 0371 covering brachytherapy, effective September 26, 2025. Here's what changes for billing teams.

Aetna, a CVS Health company, updated its brachytherapy coverage policy under CPB 0371 to formally route all medical necessity determinations through eviCore Healthcare's Radiation Therapy Clinical Guidelines. This change affects 27 CPT codes and 23 HCPCS codes — from CPT 19296 for breast brachytherapy catheter placement to CPT 55875 for transperineal prostate seed implants to the full suite of 77xxx series planning and source application codes. If your team bills brachytherapy across oncology, radiation therapy, or surgical specialties, this update changes where you look for medical necessity criteria — and when you need prior authorization.

Quick-Reference Table

Aetna Brachytherapy Coverage Criteria and Medical Necessity Requirements 2025

Aetna's brachytherapy coverage policy now delegates all medical necessity criteria to eviCore Healthcare. You won't find a payer-maintained checklist inside CPB 0371. Instead, Aetna points you directly to the eviCore Radiation Therapy Clinical Guidelines.

That's a meaningful structural shift. eviCore manages prior authorization and utilization management for Aetna on radiation oncology services. If your practice bills brachytherapy CPT codes — especially high-volume codes like CPT 77770, 77771, and 77772 for remote afterloading HDR brachytherapy, or CPT 55875 for prostate seed implants — you need to confirm medical necessity through eviCore's portal, not just Aetna's own criteria documents.

There's a catch with eviCore's guidelines. They update formally once a year, but eviCore reserves the right to change criteria without advance notice outside that cycle. Draft guidelines are posted 90 days before a scheduled implementation. In practice, your authorization approval criteria can shift mid-year without warning. Build that into your prior authorization workflow.

The policy confirms brachytherapy as medically necessary when selection criteria are met. It covers brachytherapy used alone, in combination with external beam radiation therapy, or in conjunction with surgery. Tumors near critical structures that can't be resected with adequate surgical margins are a specific supported indication for interstitial brachytherapy — worth noting when documenting medical necessity for those cases.

Reimbursement for brachytherapy under this coverage policy depends entirely on meeting eviCore's current clinical thresholds at the time of the service. Don't rely on criteria you pulled six months ago.

Aetna Brachytherapy Exclusions and Non-Covered Indications

One specific exclusion stands out in CPB 0371: ProstRcision — the combination of brachytherapy and external beam radiation therapy for prostate cancer — is explicitly not covered as superior to other established treatment options.

Aetna's position is direct. This combination approach has not been proven more effective than other established alternatives for prostate cancer treatment. That's not a blanket exclusion on all brachytherapy for prostate cancer. You can still bill CPT 55875 for transperineal prostate seed placement when criteria are met. The exclusion is specific to the ProstRcision protocol as a superior alternative claim.

Two CPT codes — 0394T and 0395T — are listed in the policy under the Xoft Axxent eBx System, flagged with "no specific code" status. These high dose rate electronic brachytherapy codes are not covered the same way as standard brachytherapy codes under this policy. If your facility uses the Xoft system, review these codes separately before submitting claims. A claim denial on 0394T or 0395T should not be a surprise — the policy signals it clearly.

Coverage Indications at a Glance

Aetna Brachytherapy Billing Guidelines and Action Items 2025

1. Pull eviCore's current Radiation Therapy Clinical Guidelines before September 26, 2025.
CPB 0371's medical necessity criteria now live in eviCore's system, not Aetna's own documentation. Download or bookmark the current guidelines at eviCore's provider portal. Know which version is active on your service date.

2. Confirm prior authorization for every brachytherapy case through eviCore — not Aetna directly.
This is the practical change that matters most. Prior authorization for brachytherapy billing on Aetna commercial plans routes through eviCore. If your staff is submitting PA requests directly to Aetna, redirect that process immediately.

3. Audit your charge capture for CPT 0394T and 0395T if you use the Xoft Axxent system.
These codes are listed under "no specific code" in the policy data. Before you bill these on any Aetna claim, verify coverage with the plan. A claim denial is the likely outcome without that confirmation.

4. Document medical necessity for ProstRcision cases carefully — or don't bill it as a superior alternative.
The policy explicitly says ProstRcision (brachytherapy combined with EBRT for prostate cancer) is not proven more effective than other established alternatives. You can still bill CPT 55875 for seed implantation in prostate cases that qualify under eviCore guidelines. But billing it as part of a ProstRcision protocol and claiming superiority over other treatments will not survive audit.

5. Watch eviCore's 90-day draft cycle — but assume mid-year changes are possible.
Set a calendar reminder to check eviCore's posted draft guidelines quarterly. They post drafts 90 days before formal implementation. But the policy reserves the right to update without notice. Monitor actively.

6. Verify ICD-10-CM diagnosis code specificity for every brachytherapy claim.
CPB 0371 maps to 407 ICD-10-CM codes across malignant neoplasms of the lip, tongue, nasopharynx, breast, prostate, cervix, skin, and dozens of other primary sites. Use the most specific code available. A claim submitted with an unspecified neoplasm code when a specific site code exists is an easy denial — and an easy fix.

If you're not sure how eviCore's delegation affects your specific plan mix, loop in your billing consultant or compliance officer before the September 26, 2025 effective date.

CPT, HCPCS, and ICD-10 Codes for Brachytherapy Under CPB 0371

Covered CPT Codes (When Selection Criteria Are Met)

Non-Covered / No Specific Code Designations

Other CPT Codes Related to CPB 0371

Covered HCPCS Codes (When Selection Criteria Are Met)

Other HCPCS Codes Related to CPB 0371

Key ICD-10-CM Diagnosis Codes (Selected from 407 Total)

The full list in CPB 0371 covers 407 ICD-10-CM codes. The codes span malignant neoplasms across the full body. Below is a representative cross-section of primary site categories covered:

The full ICD-10-CM list covers malignant neoplasms of the breast, prostate, cervix, uterus, rectum, bladder, skin, brain, and dozens of additional primary sites. Use the full code list in the source policy to confirm diagnosis code coverage for your specific cases. Aetna's CPB 0371 page at app.payerpolicy.org/p/aetna/0371. above contains the complete 407-code mapping.