Infrared Therapy — CPB 0604 | AETNA Coverage Update

Aetna modified CPB 0604 for infrared therapy, effective December 4, 2025. Here's what billing teams need to know before submitting claims.

Aetna, a CVS Health company, updated CPB 0604 — its infrared therapy coverage policy — affecting CPT 46930 and 97026 on the covered side, and HCPCS E0221 and A4639 on the non-covered side. The policy draws a hard line between infrared coagulation (covered for specific anorectal conditions) and low-level infrared light therapy (not covered for nearly three dozen diagnoses). If your practice bills infrared therapy for anything outside anal dysplasia, grade I or II hemorrhoids, or physical therapy heat modalities, expect a claim denial.

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Quick-Reference Table

Field	Detail Copy
Payer	Aetna, a CVS Health company
Policy	Infrared Therapy — CPB 0604
Policy Code	CPB 0604
Change Type	Modified
Effective Date	December 4, 2025
Impact Level	Medium — high exposure for practices billing low-level infrared for wound care, neuropathy, or pain
Specialties Affected	Gastroenterology, colorectal surgery, physical therapy, wound care, neurology
Key Action	Audit active orders for CPT 97026, E0221, and A4639 against covered indications before submitting claims dated on or after December 4, 2025

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Aetna Infrared Therapy Coverage Criteria and Medical Necessity Requirements 2025

The Aetna infrared therapy coverage policy under CPB 0604 splits infrared treatment into two distinct categories. Infrared coagulation gets covered. Low-level infrared light therapy does not — except as a heat modality in physical therapy.

Infrared coagulation (CPT 46930) meets medical necessity under two conditions:

#	Covered Indication Copy
1	Anal dysplasia
2	Grade I or grade II internal hemorrhoids that are painful or persistently bleeding

That's it. Aetna's grading criteria for internal hemorrhoids appears in the policy appendix, so your documentation needs to specify hemorrhoid grade explicitly. A chart note that says "hemorrhoids" without grading will not satisfy these criteria.

CPT 97026 — application of infrared as a physical therapy modality — is covered when used as a heat modality in a physical therapy context. This is a narrow carve-out. The code is covered, but only when it's functioning as a heat modality within a broader physical therapy treatment plan. Billing 97026 for low-level infrared therapy outside that context puts you in experimental territory.

Aetna does not specify prior authorization requirements within CPB 0604 itself. That said, prior auth requirements vary by plan. Before scheduling infrared coagulation, verify authorization requirements at the individual plan level — especially for colorectal surgery cases.

Reimbursement for CPT 46930 depends on meeting both the diagnosis criteria and the hemorrhoid grading threshold. If you're billing for grade III or grade IV hemorrhoids, this policy doesn't support coverage under infrared coagulation.

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Aetna Infrared Therapy Exclusions and Non-Covered Indications

This is where the policy gets extensive — and where most of your claim denial risk lives.

Aetna classifies low-level infrared light therapy (including the Anodyne Therapy System) as experimental, investigational, or unproven for 29 specific conditions. The list covers conditions that billing teams often assume have some coverage pathway. It doesn't.

The 29 excluded indications are:

Wound care and neuropathy are the two highest-exposure areas here. Practices that bill low-level infrared for diabetic peripheral neuropathy or chronic non-healing wounds have been doing so under an assumption of coverage that this policy explicitly rejects. That gap matters.

Two additional exclusions apply:

#	Excluded Procedure Copy
1	The infrared glove (e.g., Prolotex Therapy Glove) is not covered for Raynaud's syndrome or any other indication
2	Photo-biomodulation using infrared light-emitting diode is not covered for asthma

HCPCS codes E0221 (infrared heating pad system) and A4639 (replacement pad for infrared heating pad system) are not covered for any of the indications listed in CPB 0604. If you have durable medical equipment suppliers billing these codes for home-use infrared devices, those claims will not clear under this policy.

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Coverage Indications at a Glance

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Aetna Infrared Therapy Billing Guidelines and Action Items 2025

The effective date of December 4, 2025 is already here. These actions apply to claims you're submitting now.

Copy Action Items

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CPT, HCPCS, and ICD-10 Codes for Infrared Therapy Under CPB 0604

Covered CPT Codes (When Selection Criteria Are Met)

Code	Type	Description Copy
46930	CPT	Destruction of internal hemorrhoid(s), by thermal energy (e.g., infrared coagulation, cautery, radiofrequency)
97026	CPT	Application of a modality to one or more areas; infrared

Not Covered / Non-Covered HCPCS Codes

Code	Type	Description	Reason Copy
A4639	HCPCS	Replacement pad for infrared heating pad system, each	Not covered for indications listed in CPB 0604
E0221	HCPCS	Infrared heating pad system	Not covered for indications listed in CPB 0604

Key ICD-10-CM Diagnosis Codes

These codes appear in CPB 0604's covered and non-covered code sets. The table below focuses on the highest-volume diagnoses most likely to appear in your billing queue.

The full ICD-10 code set for CPB 0604 includes 415 codes. Review the complete list at app.payerpolicy.org/p/aetna/0604 before building out your denial management rules.

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