Magnetic Resonance Cholangiopancreatography — CPB 0384 | AETNA Coverage Update

TL;DR: Aetna, a CVS Health company, modified CPB 0384 governing MRCP coverage policy, effective September 26, 2025. Billing teams should audit their HCPCS S8037 claims and ICD-10 documentation now — before denials start stacking up.

Aetna's updated Aetna MRCP coverage policy under CPB 0384 Aetna system lays out 11 specific medical necessity criteria for magnetic resonance cholangiopancreatography. The primary billable code is HCPCS S8037, and the policy explicitly excludes CPT 0723T and 0724T — the newer quantitative MRCP codes — from coverage under any listed indication. If your team bills for hepatobiliary or pancreatic imaging, this update changes how you document and code these cases.

Quick-Reference Table

Aetna MRCP Coverage Criteria and Medical Necessity Requirements 2025

Aetna's coverage policy for MRCP is built around a clear logic: MRCP is covered when ERCP either can't be done safely, wasn't successful, or isn't yet warranted based on the diagnostic picture. That's the thread running through all 11 criteria.

Aetna considers MRCP medically necessary when any one of these conditions is met:

The real issue here is documentation specificity. Aetna doesn't just want a diagnosis code — they want evidence that one of these clinical scenarios actually applies. A claim with C25.0 (pancreatic cancer) and S8037 won't automatically pass. The documentation needs to show why MRCP was chosen over ERCP.

MRCP billing under this policy lives entirely in the HCPCS code S8037. That's the covered code. Reimbursement depends on pairing S8037 with an ICD-10 that maps cleanly to one of the 11 criteria. Your prior authorization process should reflect that mapping — not just the diagnosis, but the clinical rationale.

Aetna MRCP Exclusions and Non-Covered Indications

Two codes are explicitly excluded from coverage under CPB 0384, regardless of the clinical scenario:

These are the emerging QMRCP codes. Aetna considers them not covered for any indication listed in CPB 0384. This isn't a gray area — it's a hard exclusion.

If your radiologists have started using QMRCP protocols and billing 0723T or 0724T on Aetna patients, expect claim denial. The fix isn't documentation — it's a code change, or an appeal strategy that acknowledges you're outside this coverage policy entirely.

The policy is also silent on pancreatic cancer staging as a standalone covered indication for MRCP. The ICD-10 data flags C25.x codes (malignant neoplasm of pancreas) with a note that MRCP is not covered for staging of pancreatic cancer, except in cases where renal insufficiency or contrast allergy applies. That carve-out matters for oncology billing teams.

Coverage Indications at a Glance

Aetna MRCP Billing Guidelines and Action Items 2025

The effective date is September 26, 2025. If you haven't already reviewed your workflows against this updated policy, do it now.

If your payer mix skews heavily toward Aetna and you bill significant MRCP volume, loop in your compliance officer before the September 26 effective date. The gap between what's documented and what the policy requires is where denials accumulate.

CPT, HCPCS, and ICD-10 Codes for MRCP Under CPB 0384

Covered HCPCS Code (When Selection Criteria Are Met)

Not Covered / Experimental CPT Codes

Key ICD-10-CM Diagnosis Codes

The full list under CPB 0384 includes 588 ICD-10-CM codes. Below are the primary categories most relevant to billing teams. Reference the full policy at app.payerpolicy.org/p/aetna/0384 for the complete list.