Defecography — CPB 0718 | AETNA Coverage Update

TL;DR: Aetna, a CVS Health company, modified CPB 0718 covering defecography (evacuation proctography), effective November 14, 2025. Billing teams need to confirm documented medical necessity criteria before submitting claims on CPT codes 72195, 72196, 72197, and 74270.

Aetna defecography coverage policy CPB 0718 Aetna now draws a sharp line between conventional defecography and MR defecography — each with its own medical necessity criteria and specific covered indications. If your practice bills for pelvic floor imaging or functional defecation disorders, this policy update directly affects your reimbursement on six CPT codes and a wide range of ICD-10 diagnoses across colorectal, urogynecology, and gastroenterology.

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Quick-Reference Table

Field	Detail Copy
Payer	Aetna
Policy	Defecography — CPB 0718
Policy Code	CPB 0718
Change Type	Modified
Effective Date	November 14, 2025
Impact Level	Medium-High
Specialties Affected	Colorectal surgery, gastroenterology, urogynecology, radiology
Key Action	Audit claim documentation to confirm anorectal manometry and balloon expulsion results are on file before billing conventional defecography

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Aetna Defecography Coverage Criteria and Medical Necessity Requirements 2025

Aetna's coverage policy for defecography is a stepwise framework. You need to understand both pathways — conventional defecography first, MR defecography second — because mixing them up will produce a claim denial.

Conventional Defecography (CPT 74270)

Aetna considers conventional defecography medically necessary when three conditions are all met:

#	Covered Indication Copy
1	The member has documented chronic constipation
2	Anorectal manometry and rectal balloon expulsion results are negative or inconclusive
3	One of four specific conditions is suspected as the cause of impaired defecation

The four covered conditions are anterior rectocele (ICD-10 N81.6), enterocele after hysterectomy (N81.2, N81.3, N81.4, N81.5), inappropriate contraction of the puborectalis muscle (K62.89), and pelvic organ prolapse.

Chronic constipation has its own definition under this policy. The member must have two or more of the following symptoms for at least three months: lumpy or hard stools at least 1/4 of the time, sensation of incomplete evacuation at least 1/4 of the time, straining at defecation at least 1/4 of the time, or two or fewer bowel movements per week. This isn't optional language — Aetna's definition controls whether the medical necessity threshold is met.

The stepwise logic is unforgiving. If your documentation doesn't show the anorectal manometry result and the balloon expulsion result before the defecography order, Aetna has grounds to deny. Build that into your prior authorization workflow now, before November 14, 2025.

MR Defecography (CPT 72195, 72196, 72197)

MR defecography sits on a second tier. Aetna considers it medically necessary only for evaluation or surgical planning of obstructed defecation syndrome (K59.02) and other functional defecation disorders (K59.89) when conventional tests — including conventional defecography — have already been inconclusive.

MR defecography billing is the last resort here, not the first call. If your team is ordering MR defecography without a prior conventional defecography result on file, you're billing outside coverage criteria. The real issue is that MR defecography is faster and more comfortable for patients — but Aetna's policy doesn't reward convenience.

Prior authorization requirements are not explicitly stated in CPB 0718, but given the specificity of the stepped criteria, check your plan-level authorization requirements before scheduling. Complex pelvic floor cases often trigger pre-service review.

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Aetna Defecography Exclusions and Non-Covered Indications

Aetna draws a hard line around what it considers experimental, investigational, or unproven. These exclusions are broad — and they catch a lot of real-world clinical scenarios.

Conventional Defecography Is Not Covered For:

#	Excluded Procedure Copy
1	Routine evaluation of constipation (K59.0 and most K59.x codes — see the code table below)
2	Pre-operative prediction of low anterior resection syndrome (LARS) — billed with Z01.818

That LARS exclusion is significant for colorectal surgery practices. Surgeons may want defecography before low anterior resection to predict bowel function outcomes. Aetna won't cover it. Don't bill CPT 74270 with Z01.818 expecting reimbursement.

MR Defecography Is Not Covered For:

That last item is a trap. CPT 44157 and 44158 cover colectomy with ileal anastomosis. Surgeons who do pouch-anal anastomosis sometimes want post-surgical bowel function imaging. Aetna considers MR defecography unproven for that indication.

If your patient has a spinal cord injury (S12.000A through S14.109S) and neurogenic bowel dysfunction, Aetna will not cover MR defecography for bowel function evaluation. That's a direct statement from the policy, not an inference.

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Coverage Indications at a Glance

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Aetna Defecography Billing Guidelines and Action Items 2025

The defecography billing guidelines under CPB 0718 require tighter documentation than most practices currently maintain. Here's what to do before the November 14, 2025 effective date — and right after.

Copy Action Items

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CPT, HCPCS, and ICD-10 Codes for Defecography Under CPB 0718

Covered CPT Codes (When Selection Criteria Are Met)

Other CPT Codes Related to CPB 0718

Code	Type	Description	Note Copy
44157	CPT	Colectomy, total, abdominal, with proctectomy; with ileoanal anastomosis, includes loop ileostomy	Related; MR defecography not covered post-anastomosis
44158	CPT	Colectomy, total, abdominal, with proctectomy; with ileoanal anastomosis, creation of ileal reservoir	Related; MR defecography not covered post-anastomosis

Key ICD-10-CM Diagnosis Codes

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