Teduglutide (Gattex) — CPB 0849 | AETNA Coverage Update

Aetna modified CPB 0849 covering teduglutide (Gattex) for short bowel syndrome and related GI conditions, effective September 26, 2025. Here's what billing teams need to do.

Aetna, a CVS Health company, updated its teduglutide coverage policy under CPB 0849, reinforcing precertification requirements for teduglutide (Gattex) across all participating providers and applicable commercial plan designs. This policy affects specialty pharmacy billing teams managing high-cost GI biologics, particularly those billing for patients with short bowel syndrome (ICD-10 K91.2), Crohn's disease (K50.00–K52.9), and related intestinal failure diagnoses. If your practice or infusion center bills teduglutide, this effective date matters now.

Quick-Reference Table

Aetna Teduglutide Coverage Criteria and Medical Necessity Requirements 2025

Aetna's coverage policy for teduglutide (Gattex) under CPB 0849 requires precertification for all participating providers and members on applicable commercial plan designs. If you haven't submitted a precertification request, you don't have coverage — full stop.

Precertification calls go to (866) 752-7021. Fax requests to (888) 267-3277. For Statement of Medical Necessity (SMN) forms, use Aetna's Specialty Pharmacy Precertification portal.

Medical necessity documentation is the foundation of every teduglutide billing submission. Aetna will scrutinize the underlying diagnosis, so your ICD-10 code selection carries real weight here. The primary covered indication in the policy is short bowel syndrome, coded as K91.2 (postsurgical malabsorption, not elsewhere classified).

But the policy's ICD-10 list is broader than many billing teams expect. Aetna includes Crohn's disease (K50.00–K52.9), graft-versus-host disease (D89.810–D89.813), fistula of intestine (K63.2), necrotizing enterocolitis in newborns (P77.1–P77.9), and several oncology-related diagnoses. These are listed in the policy — but that doesn't automatically mean Aetna pays for teduglutide under each of them. Coverage depends on whether the clinical scenario meets medical necessity criteria for that specific indication.

This is where your team needs to be careful. The ICD-10 codes listed in CPB 0849 represent diagnoses Aetna associates with the drug — not a guaranteed approval list. Teduglutide billing for a patient with Type 2 diabetes (E11.0–E11.9) or radiation enteritis (T66.xxxA) requires airtight clinical documentation. If your compliance officer hasn't reviewed your teduglutide prior authorization submissions recently, now is the time.

The source policy contains no explicit exclusions section. No exclusions are documented in CPB 0849 as provided.

Medicare members follow separate criteria. Aetna's CPB 0849 applies to commercial plans only. For Medicare patients, check Aetna's Medicare Part B criteria separately.

Coverage Indications at a Glance

Aetna Teduglutide Billing Guidelines and Action Items 2025

The effective date is September 26, 2025. That's your deadline for getting your teduglutide billing process in order. Here's exactly what to do.

1. Audit every active teduglutide patient for precertification status before September 26, 2025.
If a patient is currently on Gattex and doesn't have an active precertification on file with Aetna, stop billing and start the prior authorization process immediately. A lapsed or missing precertification is a direct path to claim denial.

2. Verify the ICD-10 code on each claim matches the Aetna-listed diagnosis codes in CPB 0849.
K91.2 is your strongest code for short bowel syndrome. Cross-reference every patient's chart documentation against the 37 ICD-10 codes Aetna lists in this policy. If your team is billing a code not on that list, flag it for clinical review before submission.

3. Confirm you're using the correct precertification channel.
Phone: (866) 752-7021. Fax: (888) 267-3277. SMN forms are available through Aetna's Specialty Pharmacy Precertification page. Using the wrong channel delays the authorization and delays reimbursement. Don't assume your existing specialty pharmacy workflow routes to the right queue.

4. Separate your commercial and Medicare teduglutide authorizations.
CPB 0849 governs commercial plans only. Medicare members follow Aetna's Medicare Part B criteria. If your billing team uses the same workflow for both populations, fix that now. A commercial precertification does not transfer to a Medicare plan.

5. Tighten your medical necessity documentation for diagnoses that require strong clinical justification.
Diagnoses like Type 2 diabetes (E11.x), radiation enteritis (T66.xxxA), and mucositis (K12.31, K92.81) are listed in CPB 0849 but require strong medical necessity support. Your physician's clinical notes need to show why teduglutide is medically necessary for that specific patient — not just that the diagnosis code appears on the policy list.

6. Flag pediatric and neonatal cases for extra review.
Necrotizing enterocolitis codes P77.1–P77.9 are in the policy. Teduglutide use in newborns is a narrow, specialized clinical scenario. If your team bills these codes, loop in your compliance officer before the September 26, 2025 effective date. Also note that codes P77.4–P77.8 appear in the source policy but do not correspond to valid ICD-10-CM codes — verify with Aetna directly before using them on claims.

CPT, HCPCS, and ICD-10 Codes for Teduglutide Under CPB 0849

CPB 0849 does not list specific CPT or HCPCS billing codes in the policy data provided. Teduglutide (Gattex) is typically billed under specialty pharmacy or medical benefit channels depending on the plan design. Check with your specialty pharmacy partner or Aetna directly to confirm the applicable HCPCS code for teduglutide under your specific plan design before billing.

Key ICD-10-CM Diagnosis Codes Listed in CPB 0849

What the ICD-10 List Tells You — and What It Doesn't

The breadth of diagnoses in CPB 0849 is worth pausing on. Aetna's billing guidelines for teduglutide span oncology, transplant medicine, neonatology, and diabetic complications — a wide net for a drug with a narrow FDA approval.

The real issue: a broad ICD-10 list in a payer policy can create false confidence. Your billing team might see E11.9 on the list and assume teduglutide is covered for that patient. It's not that simple. Each code represents a clinical context where the drug might be used — not a pre-approved indication. The following reflects billing team observation, not language stated in CPB 0849: claims for diagnoses further from the primary indication tend to require more robust medical necessity documentation.

Short bowel syndrome (K91.2) is where teduglutide has the clearest coverage basis in this policy. Every other diagnosis on the list carries increasing documentation burden. Know the difference before you submit.