Prostate Biopsy — CPB 0698 | AETNA Coverage Update

Aetna modified CPB 0698 for prostate biopsy, effective March 3, 2026. Here's what changes for billing teams.

Aetna, a CVS Health company, updated its prostate biopsy coverage policy under CPB 0698 in Aetna's clinical policy bulletin system. The policy now covers a wider set of biopsy approaches — including transperineal, transrectal TRUS-guided, MRI-guided, and MRI-TRUS fusion methods — under specific medical necessity criteria. Primary codes affected include CPT 55706, 55707, 55708, 55709, 55710, 55711, 55712, 55713, 55714, and 55715, plus HCPCS G0416. If your team bills any of these codes for Aetna patients, read this before your next submission.

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Quick-Reference Table

Field	Detail Copy
Payer	Aetna, a CVS Health company
Policy	Prostate Biopsy — CPB 0698
Policy Code	CPB 0698
Change Type	Modified
Effective Date	March 3, 2026
Impact Level	High
Specialties Affected	Urology, Radiology, Interventional Radiology, Pathology
Key Action	Audit charge capture for CPT 55706–55715 and confirm all clinical criteria are documented before billing

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Aetna Prostate Biopsy Coverage Criteria and Medical Necessity Requirements 2026

The Aetna prostate biopsy coverage policy under CPB 0698 covers three distinct biopsy approaches. Each has its own medical necessity criteria. Getting the approach right determines whether you get paid.

Transperineal stereotactic template-guided saturation biopsy (CPT 55706) is covered in two situations. First, men with two prior negative biopsies and a persistently rising PSA. Second, men with atypia or high-grade prostatic intraepithelial neoplasia (PIN) found on a prior biopsy. Outside those two scenarios, Aetna calls saturation biopsy experimental and unproven. Don't bill CPT 55706 for surveillance of a known positive biopsy — Aetna will deny it.

TRUS-guided prostate biopsy (CPT 55707, 55709) meets medical necessity for diagnosis when the serum PSA is abnormal, or the digital rectal examination (DRE) is abnormal, or both. For follow-up and active surveillance, all three of these conditions must be met: life expectancy greater than five years, plus an abnormal repeat DRE and/or rising PSA and/or suspicious MRI, plus the repeat biopsy being performed in support of treatment changes or definitive treatment. All three. Not two of three.

MRI-guided and MRI-TRUS fusion biopsy (CPT 55708, 55710, 55711, 55712, 55713, 55714, 55715) — including in-bore approaches and systems like UroNav — has the tightest diagnostic criteria. For diagnosis, you need both a prior prostate biopsy or a PI-RADS 3 or greater lesion on MRI, and an abnormal repeat DRE or rising PSA. Both criteria must be present. For active surveillance, the same three-part test applies as with TRUS: life expectancy over five years, abnormal DRE and/or rising PSA and/or suspicious MRI, and a repeat biopsy tied to treatment decisions.

The real issue for billing is documentation. Whether Aetna covers a claim for any of these approaches comes down to what's in the chart. PSA values, DRE findings, MRI results, PI-RADS scores, prior biopsy history — all of it needs to be captured and submitted. A clean claim here isn't just about the right CPT code. It's about proving the clinical picture matches the criteria.

The policy also covers pelvic MRI (CPT 72195, 72196, 72197) when used in conjunction with these biopsy approaches. Bill those alongside your biopsy codes when MRI was performed as part of the workup or guidance.

CPB 0698 does not explicitly list prior authorization requirements within the policy bulletin itself. That said, Aetna prior authorization requirements for complex imaging and surgical procedures often apply at the plan level. Check the member's specific plan benefits before scheduling MRI-guided or fusion biopsies — those procedures carry the highest reimbursement and the highest prior auth risk.

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Aetna Prostate Biopsy Exclusions and Non-Covered Indications

Aetna draws a hard line on several newer technologies. These are not covered, not eligible for reimbursement, and not something you can appeal your way into — at least not with current evidence.

AI-based prostate cancer mapping software — including Unfold AI and Avenda Health's tools — is classified as experimental. CPT 0898T (noninvasive prostate cancer estimation map) falls into this bucket. Don't bill it expecting payment from Aetna.

Micro-ultrasound guided prostate biopsy (including the PRI-MUS protocol) is also experimental. If your practice has adopted this technology, understand that Aetna won't reimburse it as a standalone approach.

Contrast-enhanced ultrasound-targeted biopsy, spectral analysis by fluorescence spectroscopy (CPT 0443T), and ultrasound superb microvascular imaging for biopsy guidance are all excluded. Same reasoning — insufficient clinical evidence in the peer-reviewed literature.

Liquid biopsy for promoter methylation in prostate cancer diagnosis is experimental. This is relevant for practices using or considering emerging liquid biopsy platforms.

One specific billing limitation worth flagging: the know error® DNA Specimen Provenance Assay. This is a forensic test confirming a biopsy specimen belongs to the patient. Aetna treats it as part of the lab's internal quality control — not a separately billable service. Bill it and Aetna will deny it. It's considered integral to the biopsy itself.

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Coverage Indications at a Glance

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Aetna Prostate Biopsy Billing Guidelines and Action Items 2026

Here's what your billing team should do now — before claims start hitting denials.

Copy Action Items

If you're unsure how any of these changes apply to your payer mix or your patient population, talk to your compliance officer or billing consultant before the March 3, 2026 effective date passes without a review.

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CPT, HCPCS, and ICD-10 Codes for Prostate Biopsy Under CPB 0698

Covered CPT Codes (When Selection Criteria Are Met)

Covered HCPCS Codes (When Selection Criteria Are Met)

Code	Description Copy
G0416	Surgical pathology, gross and microscopic examinations, for prostate needle biopsy, any method

Not Covered / Experimental CPT Codes

Code	Description	Reason Copy
0443T	Real-time spectral analysis of prostate tissue by fluorescence spectroscopy, including imaging guidance	Experimental — insufficient evidence
0898T	Noninvasive prostate cancer estimation map, derived from augmentative analysis of image-guided fusion biopsy	Experimental — AI-based mapping not covered

Key ICD-10-CM Diagnosis Codes

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