Pharmacogenetic Testing — CPB 0715 | AETNA Coverage Update

TL;DR: Aetna, a CVS Health company, modified CPB 0715 — its pharmacogenetic and pharmacodynamic testing coverage policy — effective December 4, 2025. Here's what billing teams need to know about 159 affected CPT codes and a long list of tightly scoped medical necessity criteria.

This update to the Aetna pharmacogenetic testing coverage policy touches a wide range of oncology, psychiatry, neurology, and drug metabolism tests. The policy governs coding across CPT codes including 81225 (CYP2C19), 81226 (CYP2D6), 81232 (DPYD), 81162–81217 (BRCA1/BRCA2), 0037U (FoundationOne CDx), and dozens of proprietary panel codes in the 0289U–0461U range. If your practice bills pharmacogenomics or companion diagnostic testing for Aetna members, this policy directly affects your reimbursement.

---

Quick-Reference Table

Field	Detail Copy
Payer	Aetna, a CVS Health company
Policy	Pharmacogenetic Testing — CPB 0715
Policy Code	CPB 0715
Change Type	Modified
Effective Date	December 4, 2025
Impact Level	High
Specialties Affected	Oncology, Psychiatry, Neurology, Pathology/Lab, Hematology, Infectious Disease
Key Action	Audit all pharmacogenomic and companion diagnostic claims against updated indication-specific criteria before billing after December 4, 2025

---

Aetna Pharmacogenetic Testing Coverage Criteria and Medical Necessity Requirements 2025

The CPB 0715 Aetna pharmacogenetic testing coverage policy operates on a tight indication-by-indication framework. There is no blanket coverage for pharmacogenomics. Medical necessity is determined by the specific gene being tested, the specific drug being considered, and the specific diagnosis — and Aetna matches all three before approving a claim.

Several of the covered indications are companion diagnostic situations, meaning the test is only medically necessary if the member is actively being considered for a named drug. Testing done for general drug selection, population screening, or broad panel discovery will not meet medical necessity criteria under this policy.

Here are the core covered indications as written in CPB 0715:

Oncology — Covered When Selection Criteria Are Met:

Drug Metabolism — Covered When Selection Criteria Are Met:

#	Covered Indication Copy
1	CYP2C19 (CPT 81225) — covered for specific drug metabolism indications.
2	CYP2D6 (CPT 81226, and proprietary panel codes 0028U, 0070U–0076U) — covered for drug metabolism assessment meeting defined criteria.
3	DPYD (CPT 81232) — covered for members being considered for 5-fluorouracil or capecitabine, where DPYD deficiency affects drug metabolism and toxicity risk.

Neurology / Other:

#	Covered Indication Copy
1	ABCD1 gene mutation testing — covered for members being considered for elivaldogene autotemcel (Skysona) for cerebral adrenoleukodystrophy (CALD).
2	Neurofilament light chain (NfL) testing — covered when selection criteria are met. Relevant codes: 0361U, 0443U, 0547U, 83884.

Infectious Disease:

#	Covered Indication Copy
1	HCV genotype analysis (CPT 87902) — covered for persons with Hepatitis C meeting specific criteria.
2	HIV drug susceptibility phenotype prediction (CPT 87900) — covered when selection criteria are met.

Prior authorization requirements are not addressed in CPB 0715. Contact Aetna directly for plan-specific authorization requirements.

---

Aetna Pharmacogenetic Testing Exclusions and Non-Covered Indications

This is where CPB 0715 gets sharp — and where most claim denials happen.

FoundationOne Panels — Specific Carve-Outs:

Aetna explicitly calls out FoundationOne CDx (CPT 0037U) and FoundationOne Liquid CDx (CPT 0239U) as NOT medically necessary for several indications where targeted testing is available:

#	Excluded Procedure Copy
1	NSCLC + alectinib — FoundationOne CDx and FoundationOne Liquid CDx are not covered. Use targeted ALK mutation testing instead.
2	Melanoma + encorafenib — FoundationOne Liquid CDx is not covered. Use targeted BRAF V600E testing instead.
3	Ovarian cancer + olaparib — FoundationOne CDx and FoundationOne Liquid CDx are not covered. Use targeted BRCA testing (81162, 81165, 81216) instead.

Aetna's position is consistent: where a targeted single-gene or small-panel test exists, broad panels offer no proven advantage. Billing 0037U or 0239U in these situations will result in a claim denial.

Broad Pharmacogenomic Panels — Not Covered:

The following panel codes fall in the "not covered for indications listed in the CPB" group:

Psychiatric pharmacogenomics is a high-denial category under this policy. Aetna does not consider broad psychiatric gene panels medically necessary. If your practice has been billing 0173U or 0175U for depression and anxiety drug selection, expect denials.

Prescription Drug Monitoring — Not Covered:

These are not pharmacogenetic tests in the traditional sense, and Aetna keeps them clearly outside CPB 0715 coverage.

---

Coverage Indications at a Glance

---

Aetna Pharmacogenetic Testing Billing Guidelines and Action Items 2025

The effective date is December 4, 2025. If you're reading this after that date, audit retroactively and adjust prospectively now.

Copy Action Items

---

CPT, HCPCS, and ICD-10 Codes for Pharmacogenetic Testing Under CPB 0715

Covered CPT Codes (When Selection Criteria Are Met)

Not Covered / Excluded Codes

Aura Genetics EffectiveRX Panel Codes — Separate Policy Group

These codes appear in a distinct group in CPB 0715. Coverage status requires direct verification with Aetna. Prior authorization requirements are not addressed in CPB 0715. Contact Aetna directly for plan-specific authorization requirements before ordering or billing these codes.

---