Photodynamic Therapy — CPB 0375 | AETNA Coverage Update

Aetna modified CPB 0375 governing photodynamic therapy coverage, effective September 26, 2025. Here's what billing teams need to do.

Aetna, a CVS Health company, updated Clinical Policy Bulletin 0375, which controls photodynamic therapy (PDT) coverage for commercial medical plans. The CPB 0375 Aetna system covers 13 CPT codes and four HCPCS codes across dermatologic, endoscopic, and oncologic PDT applications. If your team bills CPT 96567, 96573, 96570, 96571, J7308, J7345, or J9600 for Aetna commercial members, this coverage policy update applies to you.

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Quick-Reference Table

Field	Detail Copy
Payer	Aetna (Commercial Plans)
Policy	Photodynamic Therapy — CPB 0375
Policy Code	CPB 0375
Change Type	Modified
Effective Date	September 26, 2025
Impact Level	Medium
Specialties Affected	Dermatology, Gastroenterology, Pulmonology, Oncology, Otolaryngology
Key Action	Audit charge capture and ICD-10 linkage for all PDT claims before submitting against the September 26, 2025 effective date

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Aetna Photodynamic Therapy Coverage Criteria and Medical Necessity Requirements 2025

The Aetna photodynamic therapy coverage policy divides PDT into two broad delivery methods: external application to the skin and endoscopic application to internal structures. Each method has its own covered CPT codes and its own medical necessity rules.

For external, skin-directed PDT, Aetna covers CPT 96567 and CPT 96573 when medical necessity criteria are met. CPT 96567 applies to destroying pre-malignant or malignant lesions using external light. CPT 96573 targets premalignant skin lesions specifically, including actinic keratoses.

The photosensitizing drug matters as much as the procedure code. Aetna covers HCPCS J7308 (aminolevulinic acid HCL, 20%, 354 mg) and J7345 (aminolevulinic acid HCL, 10% gel, 10 mg) when used in covered indications. Porfimer sodium (J9600, 75 mg) is covered for covered endoscopic and oncologic indications. Your ICD-10 coding must support the specific indication — Aetna's code list for this CPB runs to 527 diagnosis codes, so a mismatch between your procedure code and diagnosis will trigger a claim denial.

For endoscopic PDT, Aetna covers CPT 96570 (first 30 minutes) and CPT 96571 (each additional 15 minutes) under specific conditions. Both codes appear twice in the policy — once in the covered group and once in the not-covered group. That distinction is indication-driven. The same CPT code can be covered or denied depending entirely on what ICD-10 code you attach.

This policy covers commercial plans only. For Medicare PDT billing, Aetna directs you to Medicare Part B criteria, which are separate. Don't apply commercial CPB 0375 criteria to Medicare Advantage claims without confirming the plan-specific rules.

Prior authorization requirements for photodynamic therapy billing under Aetna commercial plans are not explicitly enumerated in the CPB text, but high-cost oncologic PDT — particularly porfimer sodium (J9600) at $750+ per unit — warrants prior auth verification before treatment. Check the specific plan's benefits configuration. A single J9600 denial without prior auth is an expensive lesson.

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Aetna Photodynamic Therapy Exclusions and Non-Covered Indications

The biggest trap in this policy is the dual-listed endoscopic codes. CPT 96570 and CPT 96571 appear in both the covered and not-covered groups. Aetna covers these codes for specific, medically necessary indications — but they are explicitly not covered when billed for indications listed elsewhere in the CPB.

The same logic applies to the related endoscopic procedure codes. CPT 31641 (bronchoscopy with tumor destruction), CPT 43228, 43229 (esophagoscopy with ablation), CPT 43270 (EGD with ablation), CPT 43272, and CPT 43278 (ERCP with ablation) are all listed as "other CPT codes related to the CPB." These aren't covered or excluded outright — they're contextually relevant, meaning Aetna may reference them when reviewing claims that include PDT codes.

HCPCS J7309 — methyl aminolevulinate (MAL), 16.8% topical — is explicitly not covered. The policy flags it as a discontinued product. If you have any charge capture templates still referencing J7309, remove it now. Any claim billed with J7309 will deny.

CPT 96574 (debridement of premalignant hyperkeratotic lesions followed by PDT) is also in the not-covered group. This code is sometimes billed as a precursor service before PDT application. Aetna's position is clear — it doesn't cover it for the indications listed in this CPB.

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Coverage Indications at a Glance

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Aetna Photodynamic Therapy Billing Guidelines and Action Items 2025

Copy Action Items

If your PDT volume is significant and your ICD-10 coding isn't already mapped to the CPB 0375 covered indications list, talk to your compliance officer before the effective date. The indication-dependent dual status of CPT 96570 and 96571 is the kind of ambiguity that generates audit exposure.

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CPT, HCPCS, and ICD-10 Codes for Photodynamic Therapy Under CPB 0375

Covered CPT Codes (When Selection Criteria Are Met)

Covered HCPCS Codes (When Selection Criteria Are Met)

Code	Type	Description Copy
J7308	HCPCS	Aminolevulinic acid HCL for topical administration, 20%, single unit dosage form (354 mg)
J7345	HCPCS	Aminolevulinic acid HCL for topical administration, 10% gel, 10 mg
J9600	HCPCS	Porfimer sodium, 75 mg

Not Covered / Excluded Codes

Other CPT Codes Related to CPB 0375

Key ICD-10-CM Diagnosis Codes

This CPB maps to 527 ICD-10-CM codes. Below are the primary covered and contextually relevant diagnosis codes. Verify your specific indication against the full Aetna CPB 0375 code list before billing.

The non-malignant dermatologic diagnoses (warts, fungal infections, viral skin conditions) are included in the CPB but map to non-covered indications. Don't attach these ICD-10 codes to PDT procedure claims expecting reimbursement. Aetna's position is that PDT for these conditions doesn't meet medical necessity standards under this policy.

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