Prostate Biopsy — CPB 0698 | AETNA Coverage Update

Aetna modified CPB 0698 covering prostate biopsy procedures, effective March 3, 2026. Here's what billing teams need to know.

Aetna, a CVS Health company, updated Clinical Policy Bulletin 0698 to clarify medical necessity criteria across multiple prostate biopsy approaches. This revision covers CPT codes 55706 through 55715, along with MRI guidance codes 72195–72197 and pathology code G0416. The update also explicitly designates several newer technologies—including AI-based prostate cancer mapping software and micro-ultrasound guided biopsy—as experimental and non-reimbursable. If your urology or radiology practice bills Aetna for prostate biopsy, this policy change touches nearly every approach you use.

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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, Pathology, Men's Health
Key Action	Audit charge capture for CPT 55706–55715 and verify documentation supports medical necessity criteria before billing any prostate biopsy claim to Aetna

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Aetna Prostate Biopsy Coverage Criteria and Medical Necessity Requirements 2026

The Aetna prostate biopsy coverage policy under CPB 0698 breaks down into three procedure categories, each with distinct medical necessity rules. Know which bucket your biopsy approach falls into before you submit a claim.

Transperineal Stereotactic Template-Guided Saturation Biopsy (CPT 55706)

Aetna covers CPT 55706—transperineal stereotactic template-guided saturation biopsy—for a narrow set of indications. Your patient needs to meet one of two criteria:

#	Covered Indication Copy
1	Two prior negative prostate biopsies with a persistently rising PSA, or
2	Histologic findings of atypia or high-grade prostatic intraepithelial neoplasia (PIN) on a prior biopsy.

That's it. Saturation biopsy for surveillance or watchful waiting on a known positive biopsy is explicitly not covered. Aetna calls it experimental for all other indications. If you're billing CPT 55706 outside these two scenarios, expect a claim denial.

TRUS-Guided Prostate Biopsy (CPT 55707, 55709)

Transrectal ultrasound-guided biopsy (CPT 55707) and transperineal ultrasound-guided biopsy (CPT 55709) are covered for diagnosis and active surveillance, but the criteria differ by use case.

For diagnosis, coverage requires an abnormal serum PSA level and/or an abnormal digital rectal examination (DRE). That's a lower bar—one or the other suffices.

For follow-up or active surveillance, Aetna requires all three of the following:

#	Covered Indication Copy
1	Life expectancy greater than five years
2	Abnormal repeat DRE and/or rising PSA and/or suspicious MRI
3	Repeat biopsy performed to support a change in treatment or to support definitive treatment

The third criterion is where claims get denied. "Just checking" doesn't qualify. The biopsy has to tie directly to a treatment decision. Document that connection explicitly in your medical records before you bill.

MRI-Guided and MRI-Fusion Biopsy (CPT 55708, 55710, 55711, 55712, 55713, 55714, 55715)

This is the most code-dense section of the policy. Aetna covers MRI-guided approaches—including in-bore MRI guidance (CPT 55713, 55714) and MRI-ultrasound fusion (CPT 55708, 55710, 55711, 55712, 55715)—but the diagnostic criteria are stricter than TRUS.

For diagnosis using MRI-guided or fusion biopsy, the patient needs both:

#	Covered Indication Copy
1	A prior prostate biopsy OR a PI-RADS 3 or greater lesion on MRI, and
2	An abnormal repeat DRE and/or rising PSA

That first criterion is a conjunction-or structure, but the second is required in all cases. A PI-RADS 3+ lesion alone isn't enough. You still need the clinical trigger of abnormal DRE or rising PSA.

For follow-up and active surveillance, the criteria match TRUS exactly: life expectancy over five years, abnormal DRE/rising PSA/suspicious MRI, and a biopsy tied to a treatment decision.

MRI imaging codes 72195 (without contrast), 72196 (with contrast), and 72197 (without and with contrast) are covered when they support the biopsy criteria above. Bill the right level—check whether contrast was used and bill accordingly.

Prior authorization requirements aren't explicitly detailed in this policy update, but MRI-guided procedures and fusion biopsies consistently trigger prior auth reviews with Aetna. Confirm prior auth requirements with your Aetna provider relations contact before scheduling these procedures.

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Aetna Prostate Biopsy Exclusions and Non-Covered Indications

Aetna's 2026 update to CPB 0698 draws a hard line on several emerging technologies. These are not covered—and billing them will generate denials.

AI-Based Prostate Cancer Mapping (CPT 0898T)
Aetna explicitly names Unfold AI and Avenda Health as examples. CPT 0898T—noninvasive prostate cancer estimation map derived from augmentative analysis—is considered experimental. Don't bill it to Aetna expecting reimbursement.

Spectral Analysis by Fluorescence Spectroscopy (CPT 0443T)
Real-time spectral analysis of prostate tissue by fluorescence spectroscopy (CPT 0443T) is non-covered. The policy lists it as experimental.

Micro-Ultrasound Guided Biopsy
Procedures using systems like the Prostate Risk Identification for Micro-Ultrasound (PRI-MUS) protocol fall under this exclusion. No CPT code for this was listed in the covered category.

Contrast-Enhanced Ultrasound-Targeted Biopsy
Not covered. The policy doesn't break out a specific CPT code, but any claim with documentation supporting contrast-enhanced ultrasound targeting will face denial.

Liquid Biopsy for Promoter Methylation
Using a liquid biopsy specifically for promoter methylation to diagnose prostate cancer is experimental under this policy.

Ultrasound Superb Microvascular Imaging
Targeting a biopsy using superb microvascular imaging is not covered.

The real issue here is that these technologies are advancing faster than Aetna's coverage policy. If your urologists are early adopters of AI-assisted planning tools or micro-ultrasound systems, they need to know these won't generate covered claims for Aetna patients—regardless of clinical outcomes data.

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Coverage Indications at a Glance

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Aetna Prostate Biopsy Billing Guidelines and Action Items 2026

Copy Action Items

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

Covered CPT Codes (When Selection Criteria Are Met)

Experimental / Non-Covered Codes

Code	Type	Description	Reason Copy
0443T	CPT	Real-time spectral analysis of prostate tissue by fluorescence spectroscopy, including imaging guidance	Experimental — insufficient evidence
0898T	CPT	Noninvasive prostate cancer estimation map derived from augmentative analysis of image-guided fusion biopsy	Experimental — AI-based mapping (e.g., Unfold AI, Avenda Health)

Key ICD-10-CM Diagnosis Codes

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