Actinic Keratoses Treatment — CPB 0567 | AETNA Coverage Update

TL;DR: Aetna, a CVS Health company, modified CPB 0567 covering actinic keratoses treatment, effective September 26, 2025. Here's what billing teams need to do before that date.

This update to the Aetna actinic keratoses treatment coverage policy clarifies the step-therapy sequence that determines which CPT codes Aetna will pay. The policy covers a wide range of procedures — from cryosurgery billed under CPT 17000 and 17003 to photodynamic therapy billed under CPT 96567 and 96573 — but only when you follow the right sequence. If your dermatology billing team isn't tracking that sequence in the chart, you're handing Aetna a reason to deny.

Quick-Reference Table

Aetna Actinic Keratoses Coverage Criteria and Medical Necessity Requirements 2025

CPB 0567 sets up a clear tier system. Understand it or expect claim denial.

First-line treatments — covered without step-therapy proof:
Aetna considers cryosurgery with liquid nitrogen medically necessary as a first-line treatment. Topical agents also qualify at this tier — specifically diclofenac, imiquimod, ingenol mebutate gel, and 5-fluorouracil (5-FU), with or without tretinoin cream. Bill these under CPT 17000 for the first lesion, CPT 17003 for the second through 14th lesion (add-on code), and CPT 17004 when you're destroying 15 or more lesions in a single session.

Surgical removal — covered when carcinoma is suspected:
Curettage or excision is medically necessary when squamous cell carcinoma is suspected and histological analysis is needed. These cases bill under the excision CPT codes (11400–11446 series, depending on body site and excised diameter). The specimen must go to pathology — no specimen submission, no coverage.

Second-line treatments — covered only after documented first-line failure:
This is where most denials happen. Aetna covers chemical peel (CPT 15789, 15793), dermabrasion (CPT 15780–15783, 15786, 15787), laser therapy, and photodynamic therapy (CPT 96567, 96573) only after a member has failed topical imiquimod, 5-FU, or cryosurgery. "Failed to adequately respond" is the exact language Aetna uses — and you need documentation that supports it.

The medical necessity bar for second-line procedures is real. If your documentation only shows that a patient "prefers" PDT or that the provider "recommends" laser therapy without charting the failed first-line course, Aetna has grounds to deny.

One thing the policy does not specify: whether prior authorization is required for second-line procedures. That depends on the specific Aetna plan. Check the plan-level benefits for prior auth requirements before scheduling PDT or dermabrasion — especially for commercial and self-funded plans, which can vary widely. If you're unsure, call Aetna or talk to your billing consultant before the September 26, 2025 effective date.

Aetna Actinic Keratoses Exclusions and Non-Covered Indications

The policy is explicit about what Aetna will not pay for.

Reflectance confocal microscopy (RCM) — billed under CPT 96931, 96932, 96933, 96934, 96935, and 96936 — is not covered for actinic keratoses under CPB 0567. These codes sit in the non-covered group. Bill one for actinic keratosis diagnosis or treatment planning and expect a denial.

The policy also excludes thermal photodynamic therapy and intense pulsed light (IPL) therapy. If your practice uses IPL for skin rejuvenation and tries to tie it to an actinic keratosis diagnosis under ICD-10 L57.0, that won't fly under this policy.

HCPCS code J7309 (methyl aminolevulinate, MAL, for topical administration — now discontinued) is also listed as not covered. If you still have J7309 in your charge master, remove it now. It's discontinued and non-covered.

Coverage Indications at a Glance

Aetna Actinic Keratoses Billing Guidelines and Action Items 2025

These are the steps your billing team needs to take before September 26, 2025.

1. Audit your charge capture for the 17000 series.
CPT 17000 (first lesion), 17003 (second through 14th lesion, add-on), and 17004 (15 or more lesions) are your primary destruction codes under this policy. Confirm your charge capture pairs the right code to the lesion count on every encounter. A mismatch here is a fast path to a claim denial.

2. Build a step-therapy documentation requirement into your intake workflow.
Before any second-line procedure — PDT, laser, dermabrasion, chemical peel — the chart must show an adequate trial of first-line treatment and why it failed. This means dates, agents used, and clinical response. Vague notes like "patient tried 5-FU" won't hold up in a medical necessity review. Talk to your clinical documentation team about adding a structured AK treatment history field.

3. Remove CPT 96931–96936 and HCPCS J7309 from your AK billing workflow.
These codes are non-covered under CPB 0567. If they appear on a claim with ICD-10 L57.0, expect a denial. Check your charge master and any macros or order sets that include these codes.

4. Confirm plan-level prior authorization requirements for second-line procedures.
The Aetna actinic keratoses coverage policy does not state a blanket prior authorization requirement, but individual plan contracts often do — especially for PDT billed under CPT 96567 or 96573. Verify prior auth requirements for each plan type in your Aetna payer mix before the effective date. If your practice sees high volume of commercial or self-funded Aetna members, loop in your billing consultant to do a plan-by-plan review.

5. Confirm specimen submission documentation for all excision claims.
Excision codes (11400–11446 series) are covered only when squamous cell carcinoma is suspected and a specimen goes to histological analysis. Your billing team needs to see pathology orders or lab results tied to the claim. No path report, no covered claim. Build a claim hold rule in your billing system to flag excision claims under L57.0 that lack a companion pathology charge.

6. Verify HCPCS codes J7308 and J7345 for PDT drug billing.
If you bill the aminolevulinic acid agents separately — Levulan Kerastick at J7308 (ALA HCl 20%, 354 mg) or Ameluz at J7345 (ALA HCl 10% gel, 10 mg) — confirm the associated CPT (96573 for Ameluz with red or blue light, 96567 for blue light PDT) is on the same claim. Unbundling or missing the drug code will affect reimbursement. Check your billing guidelines against your current PDT billing workflow.

CPT, HCPCS, and ICD-10 Codes for Actinic Keratoses Under CPB 0567

Covered CPT Codes (When Selection Criteria Are Met)

Not Covered / Experimental Codes

Covered HCPCS Codes (When Selection Criteria Are Met)

Not Covered HCPCS Codes

Key ICD-10-CM Diagnosis Codes