Aetna modified CPB 0750 for athletic pubalgia surgery, effective December 3, 2025. Here's what billing teams need to know.
Aetna, a CVS Health company, updated its athletic pubalgia surgery coverage policy under CPB 0750 to classify surgical treatment for athletic pubalgia — including pelvic floor repair — as experimental, investigational, or unproven. The same designation applies to intra-tissue percutaneous electrolysis and pulse-dose radiofrequency for groin pain. If your practice bills for any of these procedures using ICD-10 codes S39.013+ or S39.83X+, expect denials.
Quick-Reference Table
| Field | Detail |
|---|---|
| Payer | Aetna |
| Policy | Athletic Pubalgia Surgery — CPB 0750 |
| Policy Code | CPB 0750 |
| Change Type | Modified |
| Effective Date | December 3, 2025 |
| Impact Level | High |
| Specialties Affected | General surgery, orthopedic surgery, sports medicine, urology, physical medicine |
| Key Action | Audit any open or planned athletic pubalgia surgery claims before billing Aetna; these procedures are non-covered under CPB 0750 |
Aetna Athletic Pubalgia Surgery Coverage Policy and Medical Necessity Requirements 2025
The Aetna athletic pubalgia surgery coverage policy under CPB 0750 draws a hard line: surgical treatment for athletic pubalgia is not covered. Aetna classifies it as experimental, investigational, or unproven. That means no medical necessity criteria exist that will make this procedure payable under an Aetna plan.
Athletic pubalgia goes by several names — core muscle injury, sports hernia. None of those synonyms change how CPB 0750 applies. Whatever terminology appears on your operative report or referral, Aetna's position is the same.
This matters because many surgeons and patients believe "sports hernia repair" is a recognized, reimbursable procedure. Orthopedic and general surgery practices regularly schedule these cases without checking Aetna coverage requirements — because the procedure is common enough in sports medicine that it feels routine. It is not routine under this coverage policy.
If your billing team is working up a case for pelvic floor repair coded to S39.013+ or S39.83X+, coverage does not exist under this policy. Consult your payer contract and Aetna's authorization schedules separately to determine what prior authorization requirements apply. Build that coverage determination into your pre-scheduling workflow now, before cases are booked.
Aetna Athletic Pubalgia Surgery Exclusions and Non-Covered Indications
CPB 0750 lists three specific procedures as experimental, investigational, or unproven. Each one carries real claim denial risk.
Surgical treatment for athletic pubalgia (including pelvic floor repair). CPB 0750 classifies this procedure as experimental, investigational, or unproven. Aetna does not cover surgery for athletic pubalgia, regardless of how it's described — core muscle injury, sports hernia, or otherwise. The clinical rationale is that the effectiveness of surgical repair has not been established to Aetna's standard.
Intra-tissue percutaneous electrolysis for chronic groin pain. This is a newer intervention used by some sports medicine providers. Aetna considers it unproven. If your practice has started offering this as a non-surgical alternative and you're billing Aetna patients, check your reimbursement expectations now.
Pulse-dose radiofrequency for athletic pubalgia. Aetna explicitly calls this out as experimental. Pulse-dose RF is increasingly used for musculoskeletal pain, but CPB 0750 does not support claims for athletic pubalgia specifically.
The real issue here is that all three of these procedures exist in a gray zone clinically. They're used regularly in practice. They're published in medical literature. But Aetna has decided the evidence base isn't strong enough to cover any of them. That's a hard wall for billing teams — and for surgeons who need to counsel patients on out-of-pocket costs upfront.
Coverage Indications at a Glance
| Indication | Status | Notes |
|---|---|---|
| Surgical treatment for athletic pubalgia (including pelvic floor repair) | Experimental / Not Covered | Applies regardless of surgical technique or clinical terminology used |
| Intra-tissue percutaneous electrolysis for chronic groin pain | Experimental / Not Covered | No covered indication exists under CPB 0750 |
| Pulse-dose radiofrequency for athletic pubalgia | Experimental / Not Covered | Classified as experimental; expect claim denial |
Note: See ICD-10 codes listed in CPB 0750. The policy does not assign specific codes to specific procedures.
Aetna Athletic Pubalgia Surgery Billing Guidelines and Action Items 2025
The effective date of December 3, 2025 is already live. If you haven't acted on this yet, you're behind. Here's what to do now.
| # | Action Item |
|---|---|
| 1 | Pull your Aetna claim queue for athletic pubalgia billing. Search for ICD-10 codes S39.013+ and S39.83X+ on any Aetna claims submitted in the last 90 days. If those claims are for surgical repair or the other non-covered procedures, expect denials or requests for clinical review. Get ahead of it. |
| 2 | Update your pre-scheduling coverage screening. Flag any case where the planned procedure is pelvic floor repair, percutaneous electrolysis, or radiofrequency for groin pain. Before these cases are scheduled with an Aetna-insured patient, your team needs to confirm that coverage does not exist under CPB 0750. Consult your payer contract and Aetna's authorization schedules separately to determine what authorization requirements apply. |
| 3 | Update your financial counseling process. If a surgeon wants to proceed with surgical treatment for athletic pubalgia on an Aetna patient, get a signed financial responsibility agreement in place before the procedure. The patient may be responsible for the full cost. Counsel them now, not after the claim denies. |
| 4 | Brief your surgeons and sports medicine providers. Physicians in orthopedics, general surgery, and sports medicine often assume that because they do a procedure regularly, insurance covers it. They need to know that Aetna explicitly excludes surgical athletic pubalgia treatment and the two associated non-surgical interventions. This affects patient conversations and operative scheduling. |
| 5 | Check related policy CPB 0736. Aetna cross-references CPB 0736, which covers femoro-acetabular surgery for hip impingement syndrome. If your team is billing for hip and groin procedures on the same patient, the interaction between these two policies matters. Review CPB 0736 alongside CPB 0750 to understand where coverage exists and where it doesn't. |
| 6 | Audit your ICD-10 mapping for groin pain codes. The four R10.30-series codes for localized lower abdominal and groin pain are listed in CPB 0750. If these codes appear on claims paired with electrolysis or radiofrequency procedures, Aetna will treat those claims as non-covered. Confirm your charge capture doesn't auto-populate these codes on those procedure types without a coverage check. |
| 7 | Talk to your compliance officer if you're unsure how this applies to your patient mix. If your practice sees a high volume of athletes or has active Aetna contracts with significant groin or core injury cases, this policy has real revenue exposure. Your compliance officer should review your billing guidelines and financial counseling documentation before your next scheduled athletic pubalgia case. |
| Previous Version | Current Version |
|---|---|
| Coverage is considered experimental and investigational for all indications | Coverage is considered medically necessary when specific criteria are met |
| Prior authorization is not required | Prior authorization is required for initial treatment |
| Documentation must include clinical history | Documentation must include clinical history |
| Re-review every 24 months | Re-review every 12 months with updated clinical documentation |
CPT, HCPCS, and ICD-10 Codes for Athletic Pubalgia Under CPB 0750
CPB 0750 does not list specific CPT or HCPCS procedure codes as covered. The policy classifies the procedures as non-covered across the board, so no covered CPT codes exist under this policy.
Not Covered / Experimental Procedures
| Procedure | Status | Notes |
|---|---|---|
| Surgical treatment for athletic pubalgia (pelvic floor repair) | Experimental / Not Covered | Effectiveness not established per Aetna |
| Intra-tissue percutaneous electrolysis for chronic groin pain | Experimental / Not Covered | Effectiveness not established per Aetna |
| Pulse-dose radiofrequency for athletic pubalgia | Experimental / Not Covered | Effectiveness not established per Aetna |
Note: Aetna CPB 0750 does not enumerate specific CPT or HCPCS codes for these procedures. Consult your surgical coding specialist to identify the procedure codes your practice uses for these services and map them to this coverage determination.
Key ICD-10-CM Diagnosis Codes Referenced in CPB 0750
| Code | Description |
|---|---|
| R10.30 | Pain localized to other parts of lower abdomen [groin pain] |
| R10.31 | Pain localized to other parts of lower abdomen [groin pain] |
| R10.32 | Pain localized to other parts of lower abdomen [groin pain] |
| R10.33 | Pain localized to other parts of lower abdomen [groin pain] |
| S39.013+ | Strain of muscle, fascia and tendon of pelvis (athletic pubalgia) |
| S39.83X+ | Other specified injuries of pelvis (athletic pubalgia) |
All six ICD-10 codes are listed in CPB 0750. The "+" suffix on S39.013 and S39.83X indicates a 7th character is required for proper coding — most commonly "A" for initial encounter, "D" for subsequent encounter, or "S" for sequela. Confirm your coders are appending the correct 7th character or your claim will reject on formatting before it even hits coverage review.
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