Aetna modified CPB 0395 covering ethanol injection and ablation therapies, effective September 26, 2025. Here's what billing teams need to know before claims go out the door.
Aetna, a CVS Health company, updated its ethanol injection sclerotherapy coverage policy under CPB 0395 in Aetna system. This update touches four distinct indications — thyroglossal duct cysts, venous malformations, upper GI bleeding, and benign thyroid nodules — and maps to CPT codes 43236, 49185, 60300, 76942, and 77012. If your practice bills any of these procedures for Aetna members, the medical necessity criteria in this update determine whether you get paid or get a claim denial.
Quick-Reference Table
| Field | Detail |
|---|---|
| Payer | Aetna |
| Policy | Ethanol Injection for Thyroid Lesions |
| Policy Code | CPB 0395 |
| Change Type | Modified |
| Effective Date | September 26, 2025 |
| Impact Level | Medium-High |
| Specialties Affected | Interventional Radiology, General Surgery, Otolaryngology, Gastroenterology, Endocrinology |
| Key Action | Audit your charge capture for CPT 49185, 60300, 76942, and 43236 against the three-part thyroglossal duct cyst criteria before billing Aetna claims dated on or after September 26, 2025 |
Aetna Ethanol Injection Coverage Criteria and Medical Necessity Requirements 2025
CPB 0395 Aetna system governs four separate clinical scenarios. Each one has its own threshold for medical necessity. They are not interchangeable — passing criteria for one indication does not transfer to another.
Thyroglossal Duct Cysts — This is the tightest gating in the policy. Aetna covers ethanol injection sclerotherapy for thyroglossal duct cysts only when all three of the following criteria are met simultaneously:
| # | Covered Indication |
|---|---|
| 1 | The lesion is monocystic |
| 2 | Cystographic studies confirm no extravasation |
| 3 | Cytologic studies confirm the lesion is benign |
All three must be present. Miss any one of them and Aetna considers the procedure experimental, investigational, or unproven — and will deny the claim. Aetna does allow repeat injections after one month for documented recurrence, but that allowance only applies when the original procedure was medically necessary under these same three criteria.
When billing thyroglossal duct cyst cases, CPT 60300 (aspiration and/or injection, thyroid cyst) is the primary procedural code. If imaging guidance is used, add CPT 76942 for ultrasonic guidance or CPT 77012 for CT guidance. Your documentation must support all three criteria — monocystic lesion, no extravasation on cystography, and benign cytology — or you are billing into a denial.
Symptomatic Venous Malformations of the Head and Neck — Aetna's Aetna ethanol injection coverage policy is more permissive here. No multi-part criterion list. The coverage requirement is that the venous malformation is symptomatic. Make sure your documentation establishes symptoms clearly. Vague chart notes about an incidental finding will not support medical necessity.
Overt Upper GI Bleeding — Absolute ethanol injection for overt upper gastrointestinal bleeding is covered. The operative word is "absolute" ethanol — this is not the same as ethanol sclerotherapy. CPT 43236 (esophagogastroduodenoscopy with directed submucosal injection) is the relevant procedure code here. Pair it with the appropriate K-series or K92.2 ICD-10 codes from the list below.
Benign Thyroid Nodules — Ethanol ablation for benign thyroid nodules is covered. No layered criteria beyond the benign designation. Your ICD-10 coding should reflect D34 (benign neoplasm of thyroid gland) to align with this indication. Note that C73 (malignant neoplasm of thyroid gland) appears in the code set, which creates some documentation complexity — see the billing guidelines section below.
Prior authorization requirements under this policy are not explicitly detailed in the CPB 0395 summary. That does not mean prior auth is not required for your specific Aetna plan type or market. Check plan-level benefits before assuming open access, especially for interventional radiology cases involving CPT 77012 or 76942.
Aetna Ethanol Injection Exclusions and Non-Covered Indications
The exclusion here is narrow but important. Aetna considers ethanol injection sclerotherapy for thyroglossal duct cysts experimental, investigational, or unproven when the three-part selection criteria are not fully satisfied.
This is not a blanket exclusion on the procedure. It is a conditional exclusion tied to documentation. If the cyst is multicystic rather than monocystic, the procedure is not covered. If cystography was not performed or shows extravasation, not covered. If cytology was not obtained or shows an atypical or malignant finding, not covered.
The real issue here is documentation sequencing. These studies — cystography and cytology — must happen before the procedure, and your chart needs to show they were reviewed and met criteria before the injection was performed. Retroactive documentation will not hold up on appeal.
Coverage Indications at a Glance
| Indication | Coverage Status | Relevant CPT Codes | Key Notes |
|---|---|---|---|
| Thyroglossal duct cyst — monocystic, no extravasation, benign cytology | Covered | 60300, 76942, 77012 | All three criteria must be met simultaneously |
| Thyroglossal duct cyst — criteria not met | Experimental/Not Covered | 60300 | Multicystic, extravasation present, or malignant/atypical cytology |
| Repeat injection for thyroglossal duct cyst recurrence (after 1 month) | Covered | 60300 | Only when original procedure met all three criteria |
| Symptomatic venous malformations, head and neck | Covered | 49185, 76942 | Documentation must establish symptoms |
| Overt upper GI bleeding (absolute ethanol injection) | Covered | 43236 | Use K-series or K92.2 ICD-10 codes |
| Benign thyroid nodules (ethanol ablation) | Covered | 60300, 76942, 77012 | ICD-10 D34 preferred; verify plan-level prior auth |
Aetna Ethanol Injection Billing Guidelines and Action Items 2025
These steps apply to claims dated on or after September 26, 2025.
| # | Action Item |
|---|---|
| 1 | Audit your thyroglossal duct cyst documentation templates now. Your pre-procedure note must capture three things: the monocystic nature of the lesion, cystographic results confirming no extravasation, and cytologic findings confirming benign status. If your current template does not prompt for all three, update it before your next Aetna case. |
| 2 | Separate your ICD-10 coding by indication. D34 belongs on benign thyroid nodule ablation claims. Q89.2 belongs on thyroglossal duct cyst claims. C73 is in the code set and represents malignant thyroid — if you're billing ethanol procedures with C73 as the primary diagnosis, your documentation better explain why an experimental or investigational exception does not apply, or expect scrutiny. |
| 3 | Check plan-level prior authorization for CPT 76942 and 77012. Imaging guidance codes draw prior auth requirements on many Aetna commercial plans even when the underlying procedure is covered. A denied claim on 76942 is a recoverable error. A denied claim on 76942 that also pulls 60300 into a bundling dispute is not. |
| 4 | Bill CPT 43236 correctly for GI bleeds. Ethanol injection billing for upper GI bleeding runs through endoscopy. CPT 43236 covers the EGD with directed submucosal injection. Code the ICD-10 to the specific K28.x ulcer code or K92.2 for unspecified hemorrhage — whichever matches the procedure note. Do not default to K92.2 when a more specific code is documented. |
| 5 | Flag venous malformation cases for symptom documentation review before claim submission. The coverage requirement for venous malformations is symptomatic. If the documentation shows an incidental finding managed electively without noted symptoms, the claim is at risk. A single sentence in the procedure note confirming the patient's symptoms — pain, swelling, functional limitation — supports medical necessity and protects reimbursement. |
| 6 | If your practice spans multiple Aetna plan types (commercial fully insured, ASO, Aetna Medicare Advantage), do not assume CPB 0395 applies uniformly. ASO plans can carve out or modify coverage policies. Talk to your compliance officer if you have significant Aetna volume and uncertainty about plan-level application of this policy before the effective date passes. |
| 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 Ethanol Injection Under CPB 0395
CPT Codes
| Code | Description | Policy Group |
|---|---|---|
| 43236 | Esophagogastroduodenoscopy, flexible, transoral; with directed submucosal injection(s), any substance | Ethanol ablation (no specific code — use 43236 for GI indications) |
| 49185 | Sclerotherapy of a fluid collection (e.g., lymphocele, cyst, or seroma), percutaneous, including contrast injection(s), sclerotherapeutic agent injection(s), and imaging guidance | Ethanol ablation (no specific code) |
| 60300 | Aspiration and/or injection, thyroid cyst | Other CPT codes related to CPB 0395 |
| 76942 | Ultrasonic guidance for needle placement (e.g., biopsy, aspiration, injection, localization device), imaging supervision and interpretation | Other CPT codes related to CPB 0395 |
| 77012 | Computed tomography guidance for needle placement (e.g., biopsy, aspiration, injection, localization device), radiological supervision and interpretation | Other CPT codes related to CPB 0395 |
Key ICD-10-CM Diagnosis Codes
Thyroid and Endocrine Indications
| Code | Description |
|---|---|
| C73 | Malignant neoplasm of thyroid gland |
| D34 | Benign neoplasm of thyroid gland |
| Q89.2 | Congenital malformations of other endocrine glands (thyroglossal duct cyst) |
| D11.0 | Benign neoplasm of parotid gland (Warthin's tumor) |
Overt Upper Gastrointestinal Bleeding
| Code | Description |
|---|---|
| K28.0 | Gastrojejunal ulcer, acute with hemorrhage |
| K28.1 | Gastrojejunal ulcer, acute with perforation |
| K28.2 | Gastrojejunal ulcer, acute with both hemorrhage and perforation |
| K28.3 | Gastrojejunal ulcer, acute without hemorrhage or perforation |
| K28.4 | Gastrojejunal ulcer, chronic or unspecified with hemorrhage |
| K28.5 | Gastrojejunal ulcer, chronic or unspecified with perforation |
| K28.6 | Gastrojejunal ulcer, chronic or unspecified with both hemorrhage and perforation |
| K28.7 | Gastrojejunal ulcer, chronic without hemorrhage or perforation |
| K28.8 | Gastrojejunal ulcer, unspecified as acute or chronic without hemorrhage or perforation |
| K28.9 | Gastrojejunal ulcer, unspecified as acute or chronic without hemorrhage or perforation |
| K29.71 | Gastritis, unspecified, with bleeding |
| K92.2 | Gastrointestinal hemorrhage, unspecified |
Lumbar Disc Herniation (Also Listed in CPB 0395)
| Code | Description |
|---|---|
| M51.05 | Intervertebral disc disorders with myelopathy, thoracolumbar region |
| M51.06 | Intervertebral disc disorders with myelopathy, lumbar region |
| M51.15 | Intervertebral disc disorders with radiculopathy, thoracolumbar region |
| M51.16 | Intervertebral disc disorders with radiculopathy, lumbar region |
| M51.17 | Intervertebral disc disorders with radiculopathy, lumbosacral region |
| M51.25 | Other intervertebral disc displacement, thoracolumbar region |
| M51.26 | Other intervertebral disc displacement, lumbar region |
| M51.27 | Other intervertebral disc displacement, lumbosacral region |
| M51.35 | Other intervertebral disc degeneration, thoracolumbar region |
| M51.360–M51.369 | Other intervertebral disc degeneration, lumbar region (with site specificity) |
| M51.370–M51.379 | Other intervertebral disc degeneration, lumbosacral region (with site specificity) |
| M51.45 | Schmorl's nodes, thoracolumbar region |
| M51.46 | Schmorl's nodes, lumbar region |
| M51.47 | Schmorl's nodes, lumbosacral region |
| M51.85 | Other intervertebral disc disorders, thoracolumbar region |
| M51.86 | Other intervertebral disc disorders, lumbar region |
| M51.87 | Other intervertebral disc disorders, lumbosacral region |
| M51.9 | Unspecified thoracic, thoracolumbar, and lumbosacral intervertebral disc disorder |
| M51.A0–M51.A5 | Other lumbar and lumbosacral annulus fibrosus disc defects |
Endometrioma
| Code | Description |
|---|---|
| N80.0 | Endometriosis of uterus |
| N80.1 | Endometriosis of ovary |
| N80.2 | Endometriosis of fallopian tube |
| N80.3 | Endometriosis of pelvic peritoneum |
| N80.4 | Endometriosis of rectovaginal septum and vagina |
| N80.5 | Endometriosis of intestine |
| N80.6 | Endometriosis in cutaneous scar |
| N80.7 | Endometriosis of other specified sites |
| N80.8 | Endometriosis, unspecified |
| N80.9 | Endometriosis, unspecified |
| N80.A0–N80.D9 | Additional endometriosis specificity codes |
A note on the lumbar disc and endometrioma codes: These ICD-10 groups appear in the CPB 0395 code set, which reflects the policy's coverage of sclerotherapy for cystic structures beyond just thyroid indications. CPT 49185 (percutaneous sclerotherapy of fluid collections) connects to the lumbar disc and endometrioma indications in the policy. If your practice bills ethanol sclerotherapy for these indications under Aetna, confirm that the specific indication maps to a covered clinical scenario under this policy before claim submission.
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