TL;DR: Aetna, a CVS Health company, reaffirmed its position that epiretinal radiation therapy is experimental and not covered under CPB 0756, effective December 3, 2025. If your practice treats age-related macular degeneration and has ever billed — or considered billing — for this procedure, here's what changes for your billing team.
The Aetna epiretinal radiation therapy coverage policy under CPB 0756 Aetna system was modified on December 3, 2025. The policy covers CPT code 67036 and ICD-10 codes H35.30–H35.389, and it draws a hard line: this procedure does not meet medical necessity criteria for any indication. Claims will be denied. Full stop.
Quick-Reference Table
| Field | Detail |
|---|---|
| Payer | Aetna, a CVS Health company |
| Policy | Epiretinal Radiation Therapy |
| Policy Code | CPB 0756 |
| Change Type | Modified |
| Effective Date | December 3, 2025 |
| Impact Level | High — blanket non-coverage for all indications |
| Specialties Affected | Ophthalmology, retinal surgery, radiation oncology |
| Key Action | Audit any pending or recurring claims involving epiretinal radiation therapy before billing Aetna patients — denials are guaranteed |
Aetna Epiretinal Radiation Therapy Coverage Criteria and Medical Necessity Requirements 2025
The short version: there are no coverage criteria. Aetna does not cover epiretinal radiation therapy under any clinical circumstances.
Under CPB 0756 Aetna system, the payer's position is that insufficient clinical evidence supports this treatment for age-related macular degeneration (AMD) or any other condition. That word "any" is doing a lot of work here. This isn't a narrow exclusion with carve-outs for certain patient populations or clinical protocols. It's a blanket denial.
From a medical necessity standpoint, Aetna will not recognize epiretinal radiation therapy as medically necessary regardless of diagnosis, provider documentation, or clinical rationale submitted. No amount of chart documentation will flip this to a covered service under the current policy.
This is the type of coverage policy that trips up ophthalmology billing teams who are tracking emerging AMD treatments and may see this procedure offered at academic centers or through investigational protocols. If a patient receives this treatment and you attempt to bill Aetna, expect a claim denial. The policy leaves no room for interpretation.
Prior authorization is not a path around this. Some billing teams assume that getting a prior auth approval creates a coverage obligation. That logic breaks down when the procedure is classified as experimental and investigational — prior authorization requests for non-covered services can still be denied, and an inadvertent approval doesn't guarantee payment. Don't rely on a prior auth to validate billing for epiretinal radiation therapy under Aetna.
Aetna Epiretinal Radiation Therapy Exclusions and Non-Covered Indications
Aetna classifies epiretinal radiation therapy as experimental, investigational, or unproven. That three-part label — experimental, investigational, or unproven — is intentional and consequential.
Each classification carries the same billing outcome: no reimbursement. But the language matters for appeals. "Experimental" and "investigational" often tie to clinical trial contexts. "Unproven" means the evidence base simply hasn't crossed the threshold Aetna requires for coverage. The policy uses all three terms together, which signals that Aetna is not leaving an opening for appeals based on arguing the procedure is "established in the literature."
The primary indication in scope here is age-related macular degeneration. AMD is the most common reason epiretinal radiation therapy would surface in a retina practice. Aetna explicitly calls it out, and then extends the non-coverage to "any other conditions" — a catch-all that covers off-label use as well.
For context, AMD treatment is a crowded coverage space. Aetna covers anti-VEGF injections under CPB 0701 (Vascular Endothelial Growth Factor Inhibitors for Ocular Indications). Photodynamic therapy with verteporfin is addressed under CPB 0594. Laser photocoagulation of drusen falls under CPB 0609. Epiretinal radiation therapy sits outside all of those covered pathways. It is not a billing alternative or complement to those treatments — it's a separate approach with its own non-coverage determination.
If your retina practice is billing Aetna for AMD treatment, audit your charge capture to confirm you're not inadvertently submitting epiretinal radiation codes. The exposure is real, particularly for practices that have recently added equipment or joined a clinical trial network.
Coverage Indications at a Glance
| Indication | Status | Relevant Codes | Notes |
|---|---|---|---|
| Age-related macular degeneration (AMD) | Not Covered — Experimental/Investigational/Unproven | CPT 67036; ICD-10 H35.30–H35.389 | Blanket exclusion, no exceptions listed |
| Any other condition | Not Covered — Experimental/Investigational/Unproven | CPT 67036 | Policy explicitly extends non-coverage beyond AMD to all indications |
Aetna Epiretinal Radiation Therapy Billing Guidelines and Action Items 2025
This policy is clear enough that your action items are more about prevention than process. Here's what to do before and after the December 3, 2025 effective date.
| # | Action Item |
|---|---|
| 1 | Audit your charge master and charge capture templates now. Search for CPT 67036 and any associated charge descriptions tied to epiretinal radiation therapy. Flag any line items for review. If your practice doesn't perform this procedure, confirm it. If you do, move to step two. |
| 2 | Pull any pending Aetna claims that include CPT 67036 or ICD-10 codes H35.30–H35.389 in combination with radiation therapy documentation. Review them for accuracy before they go out. A claim that goes out after December 3, 2025 for this procedure will be denied. |
| 3 | Do not submit prior authorization requests for epiretinal radiation therapy as a coverage workaround. Prior auth doesn't create coverage for experimental procedures. A PA request that slips through does not obligate Aetna to pay, and it creates false confidence in your billing workflow. |
| 4 | Educate your clinical and front-desk teams. If your physicians are discussing epiretinal radiation therapy with AMD patients who carry Aetna coverage, those patients need to understand this is not a covered service. Document those conversations. Billing a non-covered experimental procedure without patient acknowledgment creates both a claim denial and a compliance problem. |
| 5 | Review your explanation of benefits (EOB) process for any recently denied claims. If you've already received denials tied to epiretinal radiation therapy billing for Aetna patients, the denial reason code should reference experimental or investigational status. Don't appeal based on medical necessity documentation alone — the policy forecloses that path. If you have a denial with unusual characteristics that doesn't fit this pattern, talk to your compliance officer before taking action. |
| 6 | Cross-reference CPB 0756 against related Aetna policies if you're billing multiple AMD treatments. The related policies — particularly CPB 0701 for anti-VEGF agents and CPB 0594 for photodynamic therapy — define what Aetna does cover for retinal disease. Make sure your epiretinal radiation therapy billing guidelines don't bleed into those covered service lines in your coding workflow. |
The epiretinal radiation therapy billing risk here is straightforward: any claim you submit for this service to Aetna after December 3, 2025 is a guaranteed denial. The financial exposure depends on your payer mix and procedure volume, but even one or two denied claims per month adds up in write-offs, rework costs, and staff time. The fix is clean charge capture before claims go out.
| 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 Epiretinal Radiation Therapy Under CPB 0756
CPT Codes Referenced in CPB 0756
| Code | Type | Description | Coverage Status |
|---|---|---|---|
| 67036 | CPT | Vitrectomy, mechanical, pars plana approach | Non-covered — listed as a related procedure code; epiretinal radiation therapy is classified experimental/investigational/unproven |
A note on CPT 67036 specifically: this code describes a vitrectomy approach, not epiretinal radiation therapy as a standalone procedure. Aetna lists it under "Other CPT codes related to the CPB," which tells you something important. Epiretinal radiation therapy as delivered in clinical trials often involves a vitrectomy component to place the radiation device. If your surgical workflow involves both a vitrectomy and radiation delivery, both elements of that encounter sit inside this non-coverage determination. Don't assume the vitrectomy portion is separately billable when it's performed as part of the experimental radiation procedure.
Key ICD-10-CM Diagnosis Codes
| Code Range | Description |
|---|---|
| H35.30–H35.389 | Degeneration of macula and posterior pole |
This ICD-10 range covers the full spectrum of macular degeneration diagnoses, from unspecified degeneration of the macula (H35.30) through bilateral and laterality-specific codes within the H35.3 family. Any claim pairing a code from this range with documentation of epiretinal radiation therapy will trigger the non-coverage determination under CPB 0756.
If you're billing AMD-related services more broadly — anti-VEGF injections, laser treatment, diagnostic imaging — and a patient also received epiretinal radiation therapy at another facility, make sure your documentation clearly distinguishes the covered services from the non-covered procedure. Mixed-service claims can create unnecessary scrutiny.
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