Intravenous Iron Therapy — CPB 0575 | AETNA Coverage Update

Aetna modified CPB 0575 covering intravenous iron therapy, effective February 21, 2026. Here's what billing teams need to know.

Aetna, a CVS Health company, updated its intravenous iron therapy coverage policy under CPB 0575 in the Aetna system. This policy governs medical necessity criteria and prior authorization requirements for IV iron products billed under HCPCS codes J1437, J1439, J1750, J1756, J2916, Q0138, and Q0139. The 2026 revision expands covered indications, tightens lab-value thresholds by patient population, and adds pediatric eligibility criteria for certain agents. If your team bills IV iron for CKD, heart failure, IBD, pregnancy, or cancer patients on Aetna commercial plans, review these changes now.

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Quick-Reference Table

Field	Detail Copy
Payer	Aetna, a CVS Health company
Policy	Intravenous Iron Therapy
Policy Code	CPB 0575
Change Type	Modified
Effective Date	2026-02-21
Impact Level	High
Specialties Affected	Nephrology, Oncology, Cardiology, Gastroenterology, Obstetrics, Hematology, Primary Care
Key Action	Update prior authorization workflows for ferric carboxymaltose (J1439), ferric derisomaltose (J1437), and ferumoxytol (Q0138/Q0139) before billing on or after February 21, 2026

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Aetna Intravenous Iron Therapy Coverage Criteria and Medical Necessity Requirements 2026

The real story in this update is the lab-value specificity. Aetna now defines iron deficiency anemia (IDA) differently depending on the patient's clinical context — and those definitions directly determine whether your claim is covered or denied.

For standard IDA without chronic kidney disease, coverage requires serum ferritin below 30 ng/mL or TSAT below 20%. That's the baseline. Every other patient population gets its own threshold, and they're stricter than most billing teams expect.

Non-dialysis CKD and peritoneal dialysis patients require serum ferritin below 100 ng/mL and TSAT below 40%. If ferritin lands between 100–299 ng/mL, TSAT must be below 25% to confirm IDA. Both numbers need to be in the chart.

Hemodialysis-dependent CKD patients have two qualifying pathways. The first: ferritin at or below 200 ng/mL and TSAT at or below 20%. The second: ferritin at or below 500 ng/mL, TSAT at or below 30%, hemoglobin below 10 g/dL, and no active infection. Miss the hemoglobin or the infection exclusion, and you're looking at a claim denial.

Acute or chronic inflammatory conditions use a separate threshold. Ferritin below 100 ng/mL or TSAT below 20% confirms IDA. If ferritin falls between 100–300 ng/mL, TSAT must be below 20% to confirm iron deficiency. Bill these claims against D63.8 and make sure the chart reflects the correct threshold pathway.

Cancer and chemotherapy-induced anemia adds even more complexity. Absolute iron deficiency requires ferritin below 30 ng/mL and TSAT below 20%. Functional iron deficiency in ESA-treated patients requires ferritin between 30–500 ng/mL and TSAT below 50%. Possible functional iron deficiency covers ferritin in the 500–800 ng/mL range with TSAT below 50%. These thresholds matter because the diagnosis code — D63.0 for cancer-induced anemia versus D64.81 for chemotherapy-induced — must align with the correct lab-value pathway.

Precertification Requirements

Three products require precertification on all Aetna commercial plans where the plan design includes this requirement. Those three are ferric carboxymaltose (Injectafer, J1439), ferric derisomaltose (Monoferric, J1437), and ferumoxytol (Feraheme, Q0138 for non-ESRD use, Q0139 for ESRD on dialysis).

Call (866) 752-7021 or fax the Statement of Medical Necessity form to (888) 267-3277 before the infusion. Skipping this step for these three agents means your claim starts life without authorization — and that's a problem that's expensive to fix retroactively.

Iron sucrose (J1756), iron dextran (J1750), and sodium ferric gluconate (J2916) are covered when selection criteria are met, but check your specific plan designs for prior auth requirements on these agents as well.

Ferric Carboxymaltose (Injectafer, J1439) — Who Qualifies

Members one year of age and older qualify when they have documented IDA with an unsatisfactory response, intolerance, or contraindication to oral iron — and at least one of these applies: iron loss too rapid for oral intake to compensate (including heavy uterine bleeding or autologous blood donation), GI tract disorder like IBD (Crohn's disease or ulcerative colitis) where oral iron aggravates symptoms, repeated failure to follow oral iron instructions, or decreased absorption after gastric bypass or subtotal gastric resection.

Members 18 and older also qualify for non-dialysis dependent CKD with IDA or for improving exercise capacity in NYHA Class II or III chronic heart failure with left ventricular ejection fraction below 45% and iron deficiency (ferritin below 100 ng/mL or TSAT below 20%).

That heart failure indication is worth flagging for your cardiology billing team. Diagnosis codes I50.1 through I50.9 are all listed — but the LVEF threshold and the specific ferritin/TSAT cutoffs need to be documented in the chart before you submit.

Ferric Derisomaltose (Monoferric, J1437) — Who Qualifies

Coverage criteria for ferric derisomaltose follow the same IDA indications as ferric carboxymaltose, with one key difference: the pediatric eligibility age starts at one year for some indications and 18 years for others. Confirm the age threshold against the specific clinical scenario before billing J1437 for a pediatric patient.

Restless Legs Syndrome — A Narrow but Real Indication

Ferric carboxymaltose and ferric derisomaltose are covered for restless legs syndrome (RLS) in adults 18 and older when oral iron has failed or is contraindicated. Specific ferritin threshold criteria apply — confirm against the full CPB 0575 policy text before submitting claims for G25.81. This indication comes up less often than CKD or cancer indications, but G25.81 is in the covered diagnosis code list. Make sure your neurologists and sleep medicine teams know this pathway exists.

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Aetna Intravenous Iron Therapy Exclusions and Non-Covered Indications

CPT code 0251U — the hepcidin-25 ELISA serum or plasma assay — is explicitly not covered for any indication listed in this policy. If a provider orders hepcidin testing as part of an IV iron workup, do not expect reimbursement under this CPB.

Post-operative anemia following major surgery is called out as not covered under the acute posthemorrhagic anemia code (D62). The brackets in the ICD-10 listing specifically exclude post-operative anemia following major surgery like cardiac or orthopedic procedures. Don't bill D62 to justify post-surgical IV iron and expect it to pass.

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Coverage Indications at a Glance

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Aetna Intravenous Iron Therapy Billing Guidelines and Action Items 2026

Copy Action Items

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CPT, HCPCS, and ICD-10 Codes for Intravenous Iron Therapy Under CPB 0575

Covered HCPCS Codes (When Selection Criteria Are Met)

Covered CPT Codes — Administration

Not Covered CPT Codes

Code	Type	Description	Reason Copy
0251U	CPT	Hepcidin-25, enzyme-linked immunosorbent assay (ELISA), serum or plasma	Not covered for indications listed in CPB 0575

Key ICD-10-CM Diagnosis Codes

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