Aetna modified CPB 0392 for metabolic and environmental profiling for kidney stone risk, effective January 11, 2026. Here's what billing teams need to know.
Aetna, a CVS Health company, updated its kidney stone risk assessment coverage policy under CPB 0392 Aetna system to explicitly classify several diagnostic approaches as experimental, investigational, or unproven. The policy covers 17 CPT codes — including imaging codes 72192–72197, laboratory codes 82340–84560, and the newly added Category III code 0991T for acoustic enhancer microbubble cavitation lithotripsy. If your practice handles urology, nephrology, or related metabolic lab work, this update changes what you can bill and expect reimbursement on.
Quick-Reference Table
| Field | Detail |
|---|---|
| Payer | Aetna, a CVS Health company |
| Policy | Metabolic and Environmental Profiling for Kidney Stone Risk |
| Policy Code | CPB 0392 |
| Change Type | Modified |
| Effective Date | January 11, 2026 |
| Impact Level | Medium-High |
| Specialties Affected | Urology, Nephrology, Radiology, Clinical Laboratory |
| Key Action | Audit claims for CPT 0991T, 72192–72197, and any genetic/molecular analysis codes before submitting to Aetna |
Aetna Kidney Stone Risk Assessment Coverage Criteria and Medical Necessity Requirements 2026
The Aetna kidney stone profiling coverage policy draws a hard line between supported metabolic testing and techniques the payer considers unproven. Understanding that line is where you avoid a claim denial.
Metabolic urine testing — the established workup for recurrent stone formers — remains covered when medical necessity criteria are met. This includes the core 24-hour urine panel: calcium (CPT 82340), citrate (82507), creatinine (82570), oxalate (83945), pH (83986), phosphorus (84105), urea nitrogen (84540 and 84545), and uric acid (84560). These codes appear in the "other CPT codes related to this CPB" group, which signals covered status under appropriate clinical indications.
The medical necessity standard for this panel is what you'd expect: documented recurrent urolithiasis, an ICD-10 of N20.0 (calculus of kidney), or a relevant history code like Z87.442 (personal history of urinary calculi). Without one of those anchors on the claim, expect a medical necessity denial. If your documentation doesn't support recurrent stone disease, the urine chemistry panel won't hold up on appeal either.
The policy does not specifically list prior authorization requirements for the laboratory panel. That said, Aetna plan benefits vary — particularly for high-cost outpatient lab orders. If your billing team is submitting these codes for a commercial Aetna plan with a carved-out lab benefit, verify prior authorization requirements at the plan level before the effective date. Don't assume the policy silence means the plan is silent.
Aetna Kidney Stone Risk Assessment Exclusions and Non-Covered Indications
This is where the January 11, 2026 update has real teeth. Four categories are now explicitly classified as experimental, investigational, or unproven.
1. Acoustic enhancer microbubble cavitation (AEMC) lithotripsy — CPT 0991T
This is the biggest billing flag in the update. CPT 0991T covers cystourethroscopy with low-energy lithotripsy using acoustically actuated microspheres. The technology, marketed under the Enhanced Lithotripsy System (ELS) by Avvio Medical, gets a hard non-covered designation. Aetna cites a lack of evidence to support its effectiveness. If you bill 0991T to Aetna, the claim will not pay. Full stop.
2. CT and MRI for urolithiasis screening of asymptomatic persons — CPT 72192–72197
This one is narrower than it sounds. The exclusion is specifically for asymptomatic screening. CT imaging (72192, 72193, 72194) and MRI of the pelvis (72195, 72196, 72197) for an asymptomatic patient without prior stone history or active symptoms are not covered. The clinical rationale is lack of evidence for this screening indication.
CT for a symptomatic patient presenting with flank pain or known urolithiasis is a different situation — that's diagnostic, not screening. But your documentation has to support that distinction. Billing 72192 with a vague "kidney stone evaluation" note and no documented symptomatology is the kind of thing that triggers a medical necessity denial on audit.
3. Calcifying nanoparticles for kidney stone risk assessment
No CPT code is listed for this. There's no established billing pathway for this technology under Aetna. Don't bill it.
4. Genetic and molecular analysis for kidney stone risk
Aetna explicitly excludes genetic or molecular analysis for assessing kidney stone risk. No CPT code is listed in this update for that category — but if your lab is running gene panels or molecular markers as part of a stone risk workup and billing them to Aetna, this policy puts you on notice. Those services are not covered. If your genetics or molecular pathology team runs these under a broader panel CPT, talk to your compliance officer about whether any component falls under this exclusion before the next billing cycle.
Coverage Indications at a Glance
| Indication | Status | Relevant Codes | Notes |
|---|---|---|---|
| Metabolic urine profiling for recurrent kidney stone risk | Covered (when medically necessary) | 82340, 82507, 82570, 82615, 83945, 83986, 84105, 84540, 84545, 84560 | Requires documented stone history; link to N20.0 or Z87.442 |
| CT of pelvis for symptomatic urolithiasis | Covered (implied — not excluded) | 72192, 72193, 72194 | Exclusion applies only to asymptomatic screening; document symptoms clearly |
| MRI of pelvis for symptomatic urolithiasis | Covered (implied — not excluded) | 72195, 72196, 72197 | Same documentation standard as CT — symptoms must be documented |
| CT or MRI for asymptomatic urolithiasis screening | Not Covered / Experimental | 72192–72197 | Lack of clinical evidence; Aetna explicit exclusion |
| AEMC lithotripsy (ELS system) | Not Covered / Experimental | 0991T | Insufficient evidence; Avvio Medical technology specifically cited |
| Calcifying nanoparticle kidney stone risk assessment | Not Covered / Experimental | None listed | No established CPT; do not bill |
| Genetic or molecular analysis for kidney stone risk | Not Covered / Experimental | None listed | No CPT listed; affects labs running broad gene panels for stone workup |
Aetna Kidney Stone Profiling Billing Guidelines and Action Items 2026
| # | Action Item |
|---|---|
| 1 | Pull every claim submitted with CPT 0991T before January 11, 2026. If any are pending with Aetna, withdraw them now. If any paid, your compliance officer needs to know — Aetna may recoup. This code is not covered, and submitting it after the effective date means a guaranteed denial. |
| 2 | Audit your imaging documentation for CPT 72192–72197. The exclusion targets asymptomatic screening specifically. Before submitting any pelvic CT or MRI to Aetna for kidney stone-related billing, confirm your documentation includes the presenting symptom — flank pain, hematuria, acute colic — not just a diagnostic impression. Asymptomatic screening claims will not survive a medical necessity review. |
| 3 | Verify diagnosis codes on all urine chemistry panel claims. The covered lab panel (82340, 82507, 82570, 82615, 83945, 83986, 84105, 84540, 84545, 84560) needs a supported diagnosis. N20.0 for calculus of kidney and Z87.442 for personal history of urinary calculi are your primary ICD-10 anchors. R82.991 through R82.998 for abnormal urine findings can also support coverage — but those are secondary to a documented clinical picture. Don't rely on them alone. |
| 4 | Alert your genetics and molecular pathology billing team. If anyone in your organization runs kidney stone risk panels that include genetic or molecular components and bills them to Aetna, this update is a direct signal to stop. There's no listed CPT, which means no pathway to reimbursement. If there's any ambiguity about which panels are affected, talk to your compliance officer before the next billing cycle. |
| 5 | Check plan-level prior authorization requirements for the lab panel. CPB 0392 is silent on prior authorization for the covered metabolic tests. But Aetna commercial plans often have separate benefit rules — especially for outpatient lab. Confirm prior auth requirements plan-by-plan for your highest-volume Aetna contracts. A covered service with missing prior auth is still a denial. |
| 6 | Update your charge capture for kidney stone risk workups. If your system auto-populates the urine chemistry panel with CPT 82615 (cystine and homocystine), make sure the clinical documentation supports qualitative cystine testing as part of the stone workup. It's in the policy as a covered code, but it's a less common order — don't let it auto-populate without clinical rationale attached. |
| 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 Kidney Stone Risk Profiling Under CPB 0392
Not Covered / Experimental CPT Codes
| Code | Type | Description | Reason |
|---|---|---|---|
| 0991T | CPT | Cystourethroscopy, with low-energy lithotripsy and acoustically actuated microspheres, including imaging | Experimental — AEMC lithotripsy not covered for any indication |
| 72192 | CPT | Computed tomography, pelvis; without contrast material | Not covered for asymptomatic urolithiasis screening |
| 72193 | CPT | Computed tomography, pelvis; with contrast material(s) | Not covered for asymptomatic urolithiasis screening |
| 72194 | CPT | Computed tomography, pelvis; without contrast material(s) followed by contrast material(s) and further sections | Not covered for asymptomatic urolithiasis screening |
| 72195 | CPT | Magnetic resonance imaging, pelvis; without contrast material(s) | Not covered for asymptomatic urolithiasis screening |
| 72196 | CPT | Magnetic resonance imaging, pelvis; with contrast material(s) | Not covered for asymptomatic urolithiasis screening |
| 72197 | CPT | Magnetic resonance imaging, pelvis; without contrast material(s), followed by contrast material(s) and further sequences | Not covered for asymptomatic urolithiasis screening |
Covered CPT Codes — Metabolic Urine Profiling (When Medical Necessity Is Met)
| Code | Type | Description |
|---|---|---|
| 82340 | CPT | Calcium; urine quantitative, timed specimen |
| 82507 | CPT | Citrate |
| 82570 | CPT | Creatinine; other source |
| 82615 | CPT | Cystine and homocystine, urine, qualitative |
| 83945 | CPT | Oxalate |
| 83986 | CPT | pH, body fluid, except blood |
| 84105 | CPT | Phosphorus inorganic (phosphate); urine |
| 84540 | CPT | Urea nitrogen, urine |
| 84545 | CPT | Urea nitrogen, clearance |
| 84560 | CPT | Uric acid; other source |
Key ICD-10-CM Diagnosis Codes
| Code | Description |
|---|---|
| N20.0 | Calculus of kidney |
| R82.991 | Other abnormal findings in urine |
| R82.992 | Other abnormal findings in urine |
| R82.993 | Other abnormal findings in urine |
| R82.994 | Other abnormal findings in urine |
| R82.995 | Other abnormal findings in urine |
| R82.996 | Other abnormal findings in urine |
| R82.997 | Other abnormal findings in urine |
| R82.998 | Other abnormal findings in urine |
| Z87.442 | Personal history of urinary calculi |
Get the Full Picture for CPT 82340
Track this policy across versions, search 1,500+ policies by CPT code, and get real-time alerts when any payer changes coverage.