Functional Magnetic Resonance Imaging — CPB 0739 | AETNA Coverage Update

Aetna modified CPB 0739 for functional magnetic resonance imaging (fMRI), effective November 27, 2025. Here's what changes for billing teams.

Aetna, a CVS Health company, updated its fMRI coverage policy under CPB 0739 in the Aetna system. The policy governs CPT codes 70554 and 70555 — the two codes your team bills for functional MRI of the brain. The update draws a hard line between covered pre-surgical use and a long list of conditions the payer treats as experimental. If your facility bills fMRI for anything outside that narrow pre-surgical window, expect denials.

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Quick-Reference Table

Field	Detail Copy
Payer	Aetna
Policy	Functional Magnetic Resonance Imaging
Policy Code	CPB 0739
Change Type	Modified
Effective Date	November 27, 2025
Impact Level	High
Specialties Affected	Neurosurgery, Neurology, Radiology, Epilepsy Surgery Programs
Key Action	Audit all fMRI claims billed under CPT 70554 and 70555 against the covered indication list before submitting for dates of service on or after November 27, 2025

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Aetna fMRI Coverage Criteria and Medical Necessity Requirements 2025

Aetna's fMRI coverage policy under CPB 0739 is narrow by design. The payer considers CPT 70554 and 70555 medically necessary for exactly one purpose: identifying the eloquent cortex during pre-surgical evaluation.

Three conditions qualify for covered use:

#	Covered Indication Copy
1	Brain tumors — except temporal tumors
2	Epilepsy — except temporal neocortical epilepsy
3	Vascular malformations

That's it. Medical necessity under this policy requires a documented pre-surgical context and one of those three diagnoses. The relevant ICD-10-CM codes run from C71.0–C71.9 for malignant brain neoplasms, C79.31–C79.49 for secondary malignant neoplasms, D33.0–D33.2 for benign brain neoplasms, and D43.0–D43.4 for neoplasms of uncertain behavior. Those are the codes that will support a covered claim.

If a physician orders fMRI for pre-surgical planning and the diagnosis falls outside those ICD-10 categories, the claim will not meet medical necessity criteria. Document the surgical indication clearly in the medical record before you submit.

This policy does not specify prior authorization requirements in the CPB text itself. That does not mean prior auth is off the table — Aetna plan-level rules vary, and many commercial and managed care plans add prior authorization requirements on top of CPB criteria. Check the member's specific plan benefits before billing CPT 70554 or 70555. If your team isn't doing that routinely, start now.

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Aetna fMRI Exclusions and Non-Covered Indications

This is where the policy gets expensive for billing teams who aren't paying attention.

Aetna labels fMRI experimental, investigational, or unproven for a wide range of neurological and psychiatric conditions. The payer's position is that clinical evidence does not support fMRI for diagnosis, monitoring, prognosis, or surgical management of these conditions. That language — "diagnosis, monitoring, prognosis, or surgical management" — covers virtually every clinical use case outside the pre-surgical eloquent cortex mapping described above.

The excluded indications include conditions many neurologists and psychiatrists use fMRI to study routinely. That clinical use and billable coverage are two different things is the real issue here. Researchers and academic centers run fMRI for many of these conditions. Aetna does not pay for it.

Here's the full exclusion list from CPB 0739:

Those last two are the ones that trip up billing teams the most. The policy covers fMRI for epilepsy — but not temporal neocortical epilepsy. It covers fMRI for brain tumors — but not temporal tumors. If you're at an epilepsy surgery center or a neuro-oncology program, your team must verify tumor or seizure focus location before billing. A temporal lobe tumor under C71.2 can still land a denial under this policy if the surgical site is temporal.

If your practice manages a high volume of psychiatric patients and anyone has ordered fMRI for ADHD (F90.1–F90.9), autism (F84.0–F84.9), bipolar disorder (F30.10–F31.9), schizophrenia (F20.0–F20.9), OCD (F42.2–F42.9), or anxiety (F41.0–F41.9), those claims will not be covered under this policy. Document and bill accordingly — or prepare for claim denial.

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Coverage Indications at a Glance

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Aetna fMRI Billing Guidelines and Action Items 2025

The effective date is November 27, 2025. Here's what your billing team should do now.

Copy Action Items

If you manage fMRI billing for a research-affiliated program or academic medical center, loop in your compliance officer before the November 27 effective date. The line between clinical care and research use of fMRI is real, but payers don't always distinguish between them when a claim hits their system.

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CPT, HCPCS, and ICD-10 Codes for fMRI Under CPB 0739

Covered CPT Codes (When Selection Criteria Are Met)

Code	Type	Description Copy
70554	CPT	Magnetic resonance imaging, brain, functional MRI; including test selection and administration of neurofunctional testing
70555	CPT	Magnetic resonance imaging, brain, functional MRI; requiring physician or psychologist administration of entire neurofunctional testing

Key ICD-10-CM Diagnosis Codes

Covered Diagnoses (Brain Tumors and Neoplasms)

Note on C71.2: Temporal lobe malignant neoplasm appears in the ICD-10 code set listed under this policy, but temporal tumors are explicitly excluded from covered fMRI indications. Do not bill CPT 70554 or 70555 with C71.2 expecting reimbursement under CPB 0739.

Experimental / Non-Covered Diagnosis Codes (Documented in Policy)

Claims pairing CPT 70554 or 70555 with any of these diagnosis codes will not meet Aetna's medical necessity criteria under CPB 0739.

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