Intra-coronary Hyperoxemic Therapy — CPB 0801 | AETNA Coverage Update

Aetna modified CPB 0801 for intra-coronary hyperoxemic therapy, effective December 4, 2025. Every indication under this policy is classified as experimental, investigational, or unproven — meaning no reimbursement from Aetna for any patient, any diagnosis, any setting.

Aetna, a CVS Health company, updated its Aetna intra-coronary hyperoxemic therapy coverage policy under CPB 0801 Aetna system on December 4, 2025. The policy covers a procedure also known as aqueous oxygen therapy, hyperoxemic reperfusion therapy, super-oxygenation therapy, and super-saturated oxygen infusion therapy. The update touches 22 ICD-10-CM diagnosis codes spanning acute MI, stroke, cardiogenic shock, carbon monoxide poisoning, and radiocontrast nephropathy. If your team has billed or is considering billing this therapy for Aetna members, this policy change ends that conversation.

Quick-Reference Table

Aetna Intra-Coronary Hyperoxemic Therapy Coverage Criteria and Medical Necessity Requirements 2025

There are no covered indications under this policy. That's the short version.

Aetna's position under CPB 0801 is that intra-coronary hyperoxemic therapy does not meet the threshold for medical necessity — for any patient, under any diagnosis. The payer cites insufficient clinical evidence and states the effectiveness of this approach has not been established.

This means prior authorization is irrelevant here. There's no path to authorization because there's no covered indication to authorize. If your team is calling Aetna to request prior auth for this therapy, stop. The coverage policy forecloses it from the start.

The real issue for billing teams is claim denial risk. If a provider bills this therapy for an Aetna member — regardless of the clinical rationale — the claim will deny. Knowing the specific ICD-10 codes tied to this policy lets you catch those claims before they go out, not after they come back.

Aetna Intra-Coronary Hyperoxemic Therapy Exclusions and Non-Covered Indications

Aetna classifies intra-coronary hyperoxemic therapy as experimental, investigational, or unproven across five specific indication categories. These aren't edge cases. They're the primary clinical contexts where providers use or attempt this therapy.

Carbon monoxide poisoning. ICD-10 codes T58.01X+ through T58.94X+ and exposure codes X00.1XX+ and X02.1XX+ are all in scope. Some providers have explored hyperoxemic therapy in CO poisoning. Aetna won't pay for it.

Cardiogenic shock. R57.0 is the key code here. Cardiogenic shock is already a high-acuity, high-cost scenario. Adding an unproven therapy to the claim doesn't improve your odds — it guarantees a denial.

Radiocontrast nephropathy. Codes N04.0–N05.9, N07.0–N07.9, and T50.8X5+ cover nephritis and nephropathy in this context. If a provider is using hyperoxemic therapy to manage kidney complications after contrast administration, Aetna won't cover it.

Reperfusion microvascular ischemia in acute myocardial infarction. This is the core clinical context for this therapy. Codes I21.01 through I22.9 cover STEMI and NSTEMI. The therapy is being studied specifically for post-MI reperfusion injury. Aetna still calls it experimental.

Stroke. Codes G45.0–G45.2, G45.4–G45.9 cover transient cerebral ischemic attacks. Codes I60.00–I67.2, I67.4–I69.998 cover the broader cerebrovascular disease range. Codes I97.810 through I97.821 cover intraoperative and postprocedural cerebrovascular infarctions. All excluded.

The note in the policy that this is "not an all-inclusive list" matters. Aetna is reserving the right to deny other uses of this therapy that aren't explicitly named here.

Coverage Indications at a Glance

Aetna Intra-coronary Hyperoxemic Therapy Billing Guidelines and Action Items 2025

The effective date is December 4, 2025. Here's what your team needs to do now.

If you're unsure how this policy interacts with your payer mix or contract terms, talk to your billing consultant or compliance officer before the effective date creates more exposure.

CPT, HCPCS, and ICD-10 Codes for Intra-Coronary Hyperoxemic Therapy Under CPB 0801

CPB 0801 does not list specific CPT or HCPCS procedure codes. Aetna's policy focuses on the ICD-10-CM diagnosis codes that define the scope of the non-coverage determination. Your intra-coronary hyperoxemic therapy billing exposure is tracked at the diagnosis level, not the procedure code level.

This is worth noting operationally: you may need to search your charge capture by procedure description or service category — not by CPT — to identify affected claims.

Key ICD-10-CM Diagnosis Codes Under CPB 0801