Aetna modified CPB 0725 for post-herpetic neuralgia, effective October 21, 2025. Here's what changes for billing teams.
Aetna updated Clinical Policy Bulletin 0725 governing its post-herpetic neuralgia (PHN) coverage policy. This revision updates which treatments Aetna considers experimental or unproven for PHN. If your practice bills CPT codes 62320–62327 for epidural injections or 64479–64484 for transforaminal epidural steroid injections in PHN patients, this policy directly affects your reimbursement.
Quick-Reference Table
| Field | Detail |
|---|---|
| Payer | Aetna |
| Policy | Post-Herpetic Neuralgia |
| Policy Code | CPB 0725 |
| Change Type | Modified |
| Effective Date | October 21, 2025 |
| Impact Level | High |
| Specialties Affected | Pain management, neurology, anesthesiology, primary care, infectious disease |
| Key Action | Audit active PHN claims and remove any procedures now classified as experimental — especially pulsed radiofrequency, TENS, and nerve blocks — before billing after October 21, 2025 |
Aetna Post-Herpetic Neuralgia Coverage Criteria and Medical Necessity Requirements 2025
The Aetna PHN coverage policy keeps its approved treatment list tight. Aetna considers the following medically necessary for PHN:
| # | Covered Indication |
|---|---|
| 1 | Oral antivirals |
| 2 | Gabapentin |
| 3 | Intrathecal, interlaminar, or transforaminal epidural corticosteroids |
| 4 | Lidocaine patch |
| 5 | Oral opioids |
| 6 | Pregabalin |
| 7 | Tricyclic antidepressants |
That's the full approved list. Nothing else clears the medical necessity bar under CPB 0725.
When you bill epidural corticosteroid injections for PHN, use CPT 62320, 62321, 62322, or 62323 for standard interlaminar approaches. For continuous infusion or catheter-based delivery, use CPT 62324, 62325, 62326, or 62327. Transforaminal epidural routes get billed with CPT 64479 or 64480 (cervical/thoracic) and CPT 64483 or 64484 (lumbar/sacral). These all fall under "covered if selection criteria are met" — meaning PHN diagnosis must be documented and the treatment must align with what's in the covered list above.
CPB 0725 does not specify prior authorization requirements. Verify plan-level requirements directly with Aetna before scheduling covered procedures.
Capsaicin topical (Qutenza) is handled separately. Aetna routes it through the pharmacy benefit — not the medical benefit. If your practice administers Qutenza and bills under the medical benefit, you need to confirm the patient's pharmacy plan supports it first. Medical benefit billing for Qutenza will almost certainly end in a claim denial.
Aetna Post-Herpetic Neuralgia Exclusions and Non-Covered Indications
This is where CPB 0725 gets dense — and where your billing team needs to pay close attention.
Aetna classifies 40 treatments as experimental, investigational, or unproven for PHN. That's a long list, and several are procedures that pain management practices bill regularly for other diagnoses. Billing them for PHN specifically will result in denial.
The high-risk ones for pain management billing teams:
Pulsed radiofrequency procedures — including pulsed radiofrequency of the dorsal root ganglion and combined pulsed radiofrequency with transforaminal epidural steroid injection — are explicitly experimental. CPT codes 64633 and 64634 fall into the non-covered group. So does combined nerve block and pulsed radiofrequency.
TENS — Transcutaneous electrical nerve stimulation is experimental for PHN. If a provider is using TENS as adjunct therapy and it shows up on the claim with a PHN primary diagnosis, Aetna will not pay it.
Peripheral nerve stimulation — CPT 64555 and 64575 for peripheral nerve stimulator implantation are in the experimental category. So are neurostimulator implants at CPT 63650 and 63655 for epidural electrode placement.
Nerve blocks — Intercostal nerve block (CPT 64420, 64421), stellate ganglion block (CPT 64510), and trigeminal nerve block (CPT 64400) are all non-covered for PHN. Even combination trigeminal ganglion and retrobulbar nerve block is explicitly called out.
Intravenous therapies — IV ketamine, IV lidocaine, IV antiviral therapy, IV vitamin C, and IV zinc sulfate are all experimental. If you're billing 96365–96379 or 99601–99602 for any of these in PHN patients, those claims are at risk.
Botulinum toxin — Botox for PHN is experimental. Aetna routes this through CPB 0113. Do not bill botulinum toxin injections with a primary PHN diagnosis expecting reimbursement.
Acupuncture — Non-covered for PHN specifically, governed by CPB 0135.
Topical ketamine and topical piroxicam — Both experimental. No coverage.
Ozone injection into the intervertebral foramen, laser irradiation, thermotherapy (including fire needle and moxibustion), blood-letting puncture and cupping, and acupoint herbal patching — All experimental. These appear in the policy because they're used in integrative and traditional medicine settings. They will be denied.
Carbamazepine — Frequently used for neuropathic pain, but Aetna considers it experimental for PHN specifically. If a neurologist is prescribing carbamazepine for PHN and it's being billed through the pharmacy benefit under a PHN diagnosis code, flag this for your pharmacy billing team.
Serum miR-34c-5p testing — Listed by name as experimental for both PHN diagnosis and rehabilitation evaluation. This is a newer biomarker test. Do not bill it for PHN.
The real issue here: several of these procedures are covered under other diagnoses. The denial risk comes from attaching a PHN ICD-10 code to them. Diagnosis code assignment on claims for PHN patients receiving multimodal pain treatment needs careful review.
Coverage Indications at a Glance
| Indication / Treatment | Status | Relevant Codes | Notes |
|---|---|---|---|
| Oral antivirals | Covered | — | Medical necessity met for PHN |
| Gabapentin | Covered | — | Standard PHN treatment |
| Epidural corticosteroids (interlaminar/intrathecal) | Covered | CPT 62320–62327 | Selection criteria must be met |
| Transforaminal epidural corticosteroids | Covered | CPT 64479, 64480, 64483, 64484 | Imaging guidance required |
| Lidocaine patch | Covered | — | Medical benefit or pharmacy benefit — verify plan |
| Oral opioids | Covered | — | Medical necessity documented |
| Pregabalin | Covered | — | Standard PHN treatment |
| Tricyclic antidepressants | Covered | — | Medical necessity met |
| Capsaicin topical (Qutenza) | See pharmacy benefit | — | Refer to pharmacy plan; not standard medical benefit |
| Pulsed radiofrequency (DRG) | Experimental | CPT 64633, 64634 | Non-covered for PHN |
| TENS | Experimental | — | CPB 0011 for reference |
| Peripheral nerve stimulation | Experimental | CPT 64555, 64575 | Non-covered for PHN |
| Epidural neurostimulator implant | Experimental | CPT 63650, 63655 | Non-covered for PHN |
| Intercostal nerve block | Experimental | CPT 64420, 64421 | Non-covered for PHN |
| Stellate ganglion block | Experimental | CPT 64510 | Non-covered for PHN |
| Trigeminal nerve block | Experimental | CPT 64400 | Non-covered for PHN |
| Botulinum toxin | Experimental | See CPB 0113 | Non-covered for PHN |
| IV ketamine, IV lidocaine, IV antivirals | Experimental | CPT 96365–96379 | Non-covered for PHN |
| Acupuncture | Experimental | See CPB 0135 | Non-covered for PHN |
| Topical ketamine, topical piroxicam | Experimental | — | Non-covered for PHN |
| Carbamazepine | Experimental | — | Non-covered for PHN specifically |
| Extracorporeal shockwave therapy | Experimental | CPT 0101T | Non-covered for PHN |
| Spinal cord stimulation | See CPB 0194 | CPT 63650, 63655 | Governed by separate policy |
| Serum miR-34c-5p testing | Experimental | — | Non-covered for PHN diagnosis or rehab eval |
| Gabapentin + low-level laser (combination) | Experimental | — | Gabapentin alone is covered; combined use is not |
Aetna Post-Herpetic Neuralgia Billing Guidelines and Action Items 2025
The effective date of October 21, 2025 is already here. If your billing team hasn't reviewed active PHN accounts, start now.
| # | Action Item |
|---|---|
| 1 | Audit your PHN charge capture for any of the 40 experimental procedures. Pull claims from the past 90 days with PHN ICD-10 codes attached. Look for CPT codes from the experimental list — especially 64400, 64420, 64421, 64510, 64555, 64575, 63650, 63655, 64633, 64634, and 0101T. Any of these billed with a primary PHN diagnosis after October 21, 2025 will be denied. |
| 2 | Separate PHN diagnosis codes from other active diagnoses on multimodal pain claims. If a patient has PHN plus another neuropathic pain diagnosis, and they receive a pulsed radiofrequency treatment that's covered under the other diagnosis, make sure PHN is not the primary diagnosis code on that claim. Billing guidelines for PHN are specific — the denial risk is in the diagnosis assignment, not always the procedure itself. |
| 3 | Verify pharmacy benefit coverage for Qutenza before any medical benefit billing. Aetna explicitly routes capsaicin topical (Qutenza) to the pharmacy benefit. If your practice administers it in-office and bills under the medical benefit without confirming coverage, expect a claim denial. Call the payer or check the patient's benefits before the visit. |
| 4 | Verify prior authorization requirements for covered procedures before scheduling. CPB 0725 does not specify prior authorization requirements. Check plan-level requirements directly with Aetna before scheduling epidural procedures — especially transforaminal approaches (64479, 64483), which carry higher reimbursement and more scrutiny. |
| 5 | Update your provider education materials for pain management. Physicians and mid-levels treating PHN patients need to know that pulsed radiofrequency, nerve blocks, TENS, and IV therapies will not be reimbursed by Aetna when PHN is the primary indication. If a provider is documenting PHN as the reason for those treatments, the claim will fail. Work with your medical director to update clinical documentation templates. |
| 6 | Flag carbamazepine in your pharmacy billing workflow. This one surprises people. Carbamazepine is widely used in neuropathic pain — but Aetna calls it experimental for PHN specifically. If your pharmacy team or prescribers are submitting claims with PHN diagnosis codes, they need to know about this restriction. |
| 7 | If you bill home infusion codes 99601 or 99602 for PHN patients, review the underlying drug being infused. Home infusion of IV antivirals, IV ketamine, or IV lidocaine for PHN are all experimental. These codes aren't automatically denied — but the drug being infused matters. If the infused agent falls on Aetna's experimental list for PHN, you're looking at a denial. Talk to your compliance officer if your team handles home infusion for PHN patients. |
CPT Codes for Post-Herpetic Neuralgia Under CPB 0725
CPB 0725 also references 37 HCPCS codes and 9 ICD-10-CM codes not detailed in this summary. Refer to the full policy document for the complete code set.
Covered CPT Codes (When Selection Criteria Are Met)
| Code | Description |
|---|---|
| 62320 | Injection(s) of diagnostic or therapeutic substance(s), epidural, cervical or thoracic |
| 62321 | Injection(s) of diagnostic or therapeutic substance(s), epidural, cervical or thoracic, with imaging guidance |
| 62322 | Injection(s) of diagnostic or therapeutic substance(s), epidural, lumbar or sacral |
| 62323 | Injection(s) of diagnostic or therapeutic substance(s), epidural, lumbar or sacral, with imaging guidance |
| 62324 | Injection(s) including indwelling catheter placement, continuous infusion or intermittent bolus, epidural, cervical or thoracic |
| 62325 | Injection(s) including indwelling catheter placement, with imaging guidance, epidural, cervical or thoracic |
| 62326 | Injection(s) including indwelling catheter placement, continuous infusion or intermittent bolus, epidural, lumbar or sacral |
| 62327 | Injection(s) including indwelling catheter placement, with imaging guidance, epidural, lumbar or sacral |
| 64479 | Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance, cervical or thoracic |
| +64480 | Cervical or thoracic, each additional level (add-on) |
| 64483 | Injection(s), anesthetic agent and/or steroid, transforaminal epidural, lumbar or sacral, single level |
| +64484 | Lumbar or sacral, each additional level (add-on) |
Other CPT Codes Related to This Policy
| Code | Description |
|---|---|
| 96365 | IV infusion, therapeutic/prophylactic/diagnostic, initial |
| 96366 | IV infusion, each additional hour |
| 96367 | Additional sequential IV infusion, new drug/substance |
| 96368 | Concurrent infusion |
| 96369 | Subcutaneous infusion, therapeutic, initial |
| 96370 | Subcutaneous infusion, each additional hour |
| 96371 | Additional pump set-up with subcutaneous infusion |
| 96372 | Therapeutic/prophylactic/diagnostic injection, subcutaneous or intramuscular |
| 96373 | Therapeutic injection, intra-arterial |
| 96374 | Therapeutic injection, IV push, single or initial |
| 96375 | IV push, each additional sequential new drug/substance |
| 96376 | IV push, each additional sequential same drug/substance |
| 96377 | Application of on-body injector |
| 96378 | Each additional on-body injector |
| 96379 | Unlisted therapeutic injection/infusion |
| 99601 | Home infusion/specialty drug administration, per visit |
| 99602 | Home infusion/specialty drug administration, additional hour |
Not Covered / Experimental CPT Codes for PHN
| Code | Description | Reason |
|---|---|---|
| 0101T | Extracorporeal shock wave, musculoskeletal, high energy | Experimental for PHN |
| 0228T | Injection, anesthetic/steroid, transforaminal epidural, ultrasound guidance, cervical or thoracic | Experimental for PHN |
| +0229T | Each additional level (add-on) | Experimental for PHN |
| 0230T | Injection, anesthetic/steroid, transforaminal epidural, ultrasound guidance, lumbar or sacral | Experimental for PHN |
| +0231T | Each additional level (add-on) | Experimental for PHN |
| 62281 | Injection/infusion of neurolytic substance, epidural, cervical or thoracic | Experimental for PHN |
| 62282 | Injection/infusion of neurolytic substance, epidural, lumbar or sacral | Experimental for PHN |
| 63650 | Percutaneous implantation of neurostimulator electrode array, epidural | Experimental for PHN |
| 63655 | Laminectomy for implantation of neurostimulator electrodes, plate/paddle, epidural | Experimental for PHN |
| 64400 | Injection, anesthetic agent, trigeminal nerve, any division or branch | Experimental for PHN |
| 64420 | Injection, anesthetic agent, intercostal nerve, single | Experimental for PHN |
| 64421 | Injection, anesthetic agent, intercostal nerves, multiple, regional block | Experimental for PHN |
| 64510 | Injection, anesthetic agent, stellate ganglion (cervical sympathetic) | Experimental for PHN |
| 64555 | Percutaneous implantation of neurostimulator electrodes, peripheral nerve | Experimental for PHN |
| 64575 | Incision for implantation of neurostimulator electrodes, peripheral nerve | Experimental for PHN |
| 64600–64631 | Destruction by neurolytic agent, various nerve locations (somatic and sympathetic) | Experimental for PHN |
| 64633 | Destruction by neurolytic agent (see AMA CPT codebook for full description) | Experimental for PHN |
| 64634 | Destruction by neurolytic agent (see AMA CPT codebook for full description) | Experimental for PHN |
Note: The full policy data includes additional CPT codes in the 64600 series and beyond. Review the complete CPB 0725 policy document for the exhaustive list before finalizing your PHN charge capture.
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