Hammer Toe Repair — CPB 0636 | AETNA Coverage Update

TL;DR: Aetna, a CVS Health company, modified CPB 0636 governing hammertoe repair coverage, effective December 12, 2025. Billing teams need to verify documentation meets updated medical necessity criteria before submitting claims under CPT 28285 or 28286.

Aetna's hammertoe repair coverage policy under CPB 0636 Aetna sets specific, gatekeeping criteria for surgical correction of hammertoe, claw toe, and mallet toe deformities. The two primary surgical codes affected are CPT 28285 (correction, hammertoe via interphalangeal fusion or phalangectomy) and CPT 28286 (correction, cock-up fifth toe). If your practice bills these codes for Aetna members, this update sets the exact documentation floor you need to clear—and it explicitly labels a long list of fixation implants as experimental, which kills reimbursement for those devices.

---

Quick-Reference Table

Field	Detail Copy
Payer	Aetna, a CVS Health company
Policy	Hammer Toe Repair
Policy Code	CPB 0636
Change Type	Modified
Effective Date	December 12, 2025
Impact Level	High
Specialties Affected	Podiatry, Orthopedic Surgery, General Surgery
Key Action	Audit pre-op documentation for all four medical necessity criteria before submitting CPT 28285 or 28286

---

Aetna Hammertoe Repair Coverage Criteria and Medical Necessity Requirements 2025

Aetna's hammertoe repair coverage policy is a four-part gate. All four criteria must be met before CPT 28285 or 28286 will be considered medically necessary. Miss one, and you're looking at a claim denial.

Criterion 1: Radiographic confirmation. The policy requires anterior/posterior and lateral X-ray views of the affected foot, interpreted and reported. Codes 73620 through 73630 cover the radiology side. The report must be in the record—not just a notation that imaging was done.

Criterion 2: Skeletal maturity. The patient must be skeletally mature (epiphyseal closure documented) or 18 years of age or older. Document this explicitly in the chart. Don't assume the patient's age alone is enough—the policy asks for documentation of maturity, not just age.

Criterion 3: Three months of failed conservative treatment. This is where most claims fall apart. Aetna requires documented persistent pain and difficulty walking after at least three months of conservative care directed by a healthcare professional. That conservative care must include treatments from this list:

The policy says "includes, but may not be limited to"—so this isn't an exhaustive list. But every element tried and failed needs to be in the record with dates.

Criterion 4: At least one covered clinical indication. The patient must present with one or more of the following:

One of these nine indications must appear in the documentation—ideally mapped directly to an ICD-10 code on the claim.

Aetna considers hammertoe repair experimental, investigational, or unproven when these criteria are not met. That's not a soft "may deny"—that's a hard exclusion classification. Prior authorization requirements vary by plan, but given the specificity of this policy, treat prior auth as standard practice for any Aetna hammertoe case.

---

Aetna Hammertoe Repair Exclusions and Non-Covered Indications

Two categories of service are explicitly experimental under this coverage policy. Bill these and you will not get reimbursement.

Fixation implants. Aetna's position is firm and the list is long. The following devices are experimental, investigational, or unproven for hammertoe repair:

HCPCS L8641 (metatarsal joint implant) is the code Aetna has flagged for the CannuLink device specifically. If your surgeon uses any of these implants, the implant portion will not be covered. The underlying surgical procedure may still qualify under CPT 28285 if all criteria are met—but the implant is a separate denial exposure.

Plantar plate repair. Aetna considers plantar plate repair for lesser MTP joint instability experimental. If your surgeon combines hammertoe correction with plantar plate repair, document carefully and expect the plantar plate component to be denied.

---

Coverage Indications at a Glance

---

Aetna Hammertoe Repair Billing Guidelines and Action Items 2025

This policy has teeth. The documentation bar is high, and the implant exclusions are specific. Here's what to do before December 12, 2025.

Copy Action Items

---

CPT, HCPCS, and ICD-10 Codes for Hammertoe Repair Under CPB 0636

Covered CPT Codes (When Selection Criteria Are Met)

Code	Type	Description Copy
28285	CPT	Correction, hammertoe (e.g., interphalangeal fusion, partial or total phalangectomy)
28286	CPT	Correction, cock-up fifth toe, with plastic skin closure (e.g., Ruiz-Mora type procedure)

Other CPT Codes Related to the Policy

Not Covered / Experimental HCPCS Codes

Code	Type	Description	Reason Copy
L8641	HCPCS	Metatarsal joint implant	Experimental/investigational — named fixation implants lack evidence of effectiveness

Other HCPCS Codes Related to the Policy

Key ICD-10-CM Diagnosis Codes

---