Endometrial Cancer Screening, Diagnosis, and Prognosis — CPB 0769 | AETNA Coverage Update

Aetna modified CPB 0769 for endometrial cancer screening, diagnosis, and prognosis, effective October 4, 2025. Here's what billing teams need to know.

Aetna updated its endometrial cancer coverage policy under CPB 0769. The update clarifies what's covered, what's not, and — critically — draws a hard line around a growing list of biomarker tests that will trigger claim denial. If your team bills CPT 58100, 58110, 38900, or any of the sentinel lymph node mapping codes, this policy directly affects your reimbursement.

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Quick-Reference Table

Field	Detail Copy
Payer	Aetna
Policy	Endometrial Cancer Screening, Diagnosis, and Prognosis
Policy Code	CPB 0769
Change Type	Modified
Effective Date	October 4, 2025
Impact Level	Medium
Specialties Affected	Gynecologic oncology, OB/GYN, surgical pathology, clinical lab, general surgery
Key Action	Audit charge capture for biomarker and cytology codes before billing Aetna patients after October 4, 2025

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Aetna Endometrial Cancer Coverage Criteria and Medical Necessity Requirements 2025

The Aetna endometrial cancer coverage policy under CPB 0769 covers three specific clinical scenarios. Each has clear medical necessity criteria. There is no ambiguity about which side of the line these fall on.

Endometrial biopsy for abnormal uterine bleeding. Aetna covers endometrial biopsy—CPT 58100 or add-on 58110—when used for histological tissue examination in the diagnostic workup of abnormal uterine bleeding. The clinical indication must be suspected endometrial hyperplasia or endometrial carcinoma. Biopsy for general screening in asymptomatic patients does not meet medical necessity under this policy.

Lynch syndrome surveillance. Endometrial cancer surveillance via biopsy is covered for women with Lynch syndrome. This is a narrow, defined population. Your documentation must reflect the Lynch syndrome diagnosis—use the appropriate ICD-10-CM code and make sure it's on the claim.

Tao brush as an alternative to Pipelle. Aetna explicitly accepts the endometrial brush (Tao brush) as an equivalent alternative to an endometrial suction curette like the Pipelle. This gives your providers flexibility in device selection without creating a billing problem. Both are billed under the same CPT codes.

Sentinel lymph node mapping for endometrial cancer and EIN. CPT 38792, CPT 38900, and HCPCS C7503 are covered for pathologic evaluation and surgical staging. This applies to persons with confirmed endometrial cancer and those with endometrial intraepithelial neoplasia (EIN). The inclusion of EIN is worth flagging to your surgical billing team—it expands the covered population slightly beyond just confirmed carcinoma.

Note: CPB 0769 does not address prior authorization requirements. Check plan-level PA requirements independently before scheduling sentinel lymph node mapping or other procedures under this policy.

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Aetna Endometrial Cancer Exclusions and Non-Covered Indications

This is the section that matters most for claim denial prevention. Aetna's list of experimental, investigational, or unproven services under CPB 0769 is long—and it includes some tests that labs and oncology practices have been ordering routinely.

Biomarker tests that are explicitly excluded:

Two of these deserve special attention. CPT 86305 (HE4) is a test many labs run as part of gynecologic cancer panels. Aetna explicitly considers it not covered for endometrial cancer diagnosis. If your lab orders HE4 with an endometrial cancer indication, expect a denial.

The PTEN codes—81321, 81322, and 81323—are another trap. PTEN testing has legitimate uses elsewhere, including Cowden syndrome evaluation. But under CPB 0769, Aetna considers PTEN immunohistochemistry for endometrial hyperplasia differentiation to be experimental. Make sure your clinical staff documents the specific indication when ordering these tests.

Endometrial cytology is also excluded. Aetna does not cover endometrial or cervical cytology performed alongside endometrial histology—specifically calling out TruTest™ and Gynecor™ products. If your practice uses these combination approaches, stop billing Aetna for the cytology component. The histology is covered; the cytology add-on is not.

Asymptomatic screening via transvaginal ultrasound thickness measurement is not covered. Measuring endometrial thickness as a screening test in asymptomatic post-menopausal women not using hormone replacement therapy does not meet medical necessity under this policy. This is consistent with longstanding evidence gaps on population-level screening.

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Coverage Indications at a Glance

One note on CPT 78195: this code appears in the experimental/NGAL/telomere grouping in the policy data rather than the covered group. Before billing it, confirm plan-level coverage with Aetna directly. It may reflect a data classification quirk, but you should not assume coverage.

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Aetna Endometrial Cancer Billing Guidelines and Action Items 2025

These steps apply immediately. The effective date is October 4, 2025.

Copy Action Items

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CPT, HCPCS, and ICD-10 Codes for Endometrial Cancer Under CPB 0769

Covered CPT Codes (When Selection Criteria Are Met)

Covered HCPCS Codes (When Selection Criteria Are Met)

Code	Type	Description Copy
C7503	HCPCS	Open biopsy or excision of deep cervical node(s) with intraoperative identification (e.g., mapping) of sentinel lymph node(s)

Not Covered / Experimental CPT Codes

Other CPT Codes Related to CPB 0769 (Not Independently Covered for Endometrial Indications)

Other HCPCS Codes Related to CPB 0769

ICD-10-CM Diagnosis Codes

Code	Description Copy
C54.1–C54.9	Malignant neoplasm of corpus uteri [except isthmus]
D06.0–D07.0	Carcinoma in situ of cervix uteri or other and unspecified parts of uterus

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