Therapeutic Phlebotomy — CPB 0652 | AETNA Coverage Update

TL;DR: Aetna, a CVS Health company, modified CPB 0652 governing therapeutic phlebotomy coverage, effective December 9, 2025. Billing teams need to verify diagnosis codes and hematocrit thresholds before submitting CPT 99195 claims.

This update to the Aetna therapeutic phlebotomy coverage policy adds testosterone therapy patients as a covered indication — a meaningful clinical expansion. CPT 99195 (therapeutic phlebotomy) is the primary billable code, with supporting codes 36415, 85014, and 85018 rounding out the claim picture. If your practice manages hematology, hepatology, or men's health patients with Aetna coverage, this policy change directly affects your reimbursement.

Quick-Reference Table

Aetna Therapeutic Phlebotomy Coverage Criteria and Medical Necessity Requirements 2025

The core of this coverage policy is straightforward: Aetna covers therapeutic phlebotomy under CPT 99195 for 11 specific indications. Miss the criteria, and you're looking at a claim denial. Get the documentation right, and reimbursement is clean.

The biggest addition in this update is testosterone therapy. Aetna now covers therapeutic phlebotomy as medically necessary for patients on testosterone therapy when the hematocrit is 54% or higher, or hemoglobin is 180 g/L or higher. That threshold matters — document the lab value explicitly in every claim.

Here are all 11 covered indications under the updated CPB 0652 Aetna policy:

For the three secondary polycythemia indications — A-V fistulae, cor pulmonale, and cyanotic congenital heart disease — Aetna draws a hard line at hematocrit greater than 60%. Below that threshold, the procedure is not covered under this policy.

The policy does not explicitly list prior authorization requirements within CPB 0652 itself. That said, prior auth requirements vary by plan. Check the specific member's plan before scheduling, especially for testosterone therapy patients, who are a new covered category.

When you bill CPT 99195, pair it with the correct diagnosis code. Supporting labs — CPT 85014 for hematocrit and CPT 85018 for hemoglobin — are relevant codes to include when those tests drive the medical necessity determination. If the patient's blood is drawn by venipuncture as part of the procedure, CPT 36415 is in the related code set.

Aetna Therapeutic Phlebotomy Exclusions and Non-Covered Indications

Aetna is explicit: therapeutic phlebotomy is experimental, investigational, or unproven for a list of conditions. Billing CPT 99195 against these diagnoses will produce a denial. Don't test it.

The excluded list includes some diagnoses that might feel clinically adjacent to covered indications. Hyperferritinemia in alcoholic liver disease is excluded — but non-alcoholic fatty liver disease with hyperferritinemia is covered. That distinction is intentional, and your billing team needs to understand it.

The full excluded indications list:

The chronic hepatitis C exclusion is worth flagging separately. Aetna includes a set of interferon-related HCPCS codes in CPB 0652 — J1830, J9212, J9213, J9214, J9215, J9216, Q3027, S0145, and S9559. These codes appear in the policy specifically in the context of the hepatitis C exclusion. Using therapeutic phlebotomy alongside interferon therapy for hepatitis C is not covered. If your practice manages hepatitis C patients who also happen to meet a covered indication, document the actual covered diagnosis — not the hepatitis C diagnosis — as the reason for the procedure.

Coverage Indications at a Glance

Aetna Therapeutic Phlebotomy Billing Guidelines and Action Items 2025

The effective date is December 9, 2025. If you haven't reviewed your charge capture and documentation workflows yet, do it now.

1. Add testosterone therapy as a covered diagnosis trigger in your EHR.
For patients on testosterone replacement, flag any hematocrit reading at or above 54% — or hemoglobin at or above 180 g/L — for phlebotomy billing review. This is a new covered indication. Your clinical staff and billing team both need to know it exists.

2. Document the specific lab value on every therapeutic phlebotomy claim.
For erythrocytosis (55% hematocrit threshold), secondary polycythemia (60% threshold), and testosterone therapy (54% hematocrit or 180 g/L hemoglobin), Aetna's medical necessity determination hinges on the lab value. The number needs to be in the medical record, dated, and tied to the visit. A missing or undated lab result is the fastest route to a claim denial.

3. Audit your ICD-10 usage for sickle cell crisis claims.
The policy covers sickle cell crisis — not sickle cell disease without crisis, and not hemoglobin SC disease (D57.20). Review your code selection. D57.211 through D57.219 and D57.811 through D57.819 are in scope. D57.20 is excluded.

4. Separate the NAFLD indication from alcoholic liver disease in documentation.
Non-alcoholic fatty liver disease with hyperferritinemia is covered. Hyperferritinemia in alcoholic liver disease is explicitly excluded. These conditions look similar on a lab sheet but land in completely different coverage buckets. Make sure the diagnosis in the chart clearly supports one or the other.

5. Review the interferon-related HCPCS codes in your system.
Codes J9212, J9213, J9214, J9215, J9216, J1830, Q3027, S0145, and S9559 appear in CPB 0652 in the context of the hepatitis C exclusion. If your practice bills interferon alongside phlebotomy for hepatitis C patients, those claims will not be covered. If you're unsure how this applies to your specific patient mix, talk to your compliance officer before the effective date.

6. Verify prior authorization requirements at the plan level.
CPB 0652 sets the coverage policy, but individual Aetna plan documents control prior authorization requirements. For new covered indications like testosterone therapy, confirm with Aetna whether prior auth is required before scheduling. One phone call or portal check now saves a retro-denial later.

CPT, HCPCS, and ICD-10 Codes for Therapeutic Phlebotomy Under CPB 0652

Covered CPT Codes (When Selection Criteria Are Met)

Other CPT Codes Related to CPB 0652

These codes support the claim but are not the primary billable code for therapeutic phlebotomy billing.

HCPCS Codes Related to CPB 0652 (Interferon — Hepatitis C Exclusion Context)

Key ICD-10-CM Diagnosis Codes