Teduglutide (Gattex) — CPB 0849 | AETNA Coverage Update

Aetna modified CPB 0849 for teduglutide (Gattex), effective September 26, 2025. Here's what billing teams need to know before submitting claims.

Aetna, a CVS Health company, updated its teduglutide (Gattex) coverage policy under CPB 0849 Aetna system, with a September 26, 2025 effective date. This drug — a GLP-2 analog used primarily for short bowel syndrome — carries a high per-patient cost, and Aetna requires precertification on all claims. If your team bills for teduglutide without confirming prior authorization, expect a claim denial. The ICD-10 code list tied to this policy is broad — 37 diagnosis codes covering short bowel syndrome, Crohn's disease, graft-versus-host disease, necrotizing enterocolitis, and several oncologic and gastrointestinal conditions.

Quick-Reference Table

Aetna Teduglutide Coverage Criteria and Medical Necessity Requirements 2025

The Aetna teduglutide coverage policy under CPB 0849 requires precertification for all participating providers and members in applicable plan designs. There are no exceptions for established patients. If you're billing teduglutide without an active precertification, the claim will deny.

This is a commercial medical plan policy. Medicare members follow a separate pathway — Aetna directs those cases to its Medicare Part B criteria page. Don't apply commercial CPB 0849 criteria to Medicare billing. That's a fast way to get a denial on a drug that can run $50,000–$100,000 per year per patient.

Medical necessity documentation is central to this policy. The 37 ICD-10 codes on the list represent the diagnosis universe Aetna considers relevant to teduglutide use. Your clinical documentation must map cleanly to one of these codes before you submit for precertification. K91.2 (postsurgical malabsorption, short bowel syndrome) is the anchor diagnosis for most teduglutide cases, but the policy list also includes K50.00–K52.9 for Crohn's disease, D89.810–D89.813 for graft-versus-host disease, and several necrotizing enterocolitis codes (P77.1–P77.9) for pediatric cases.

The real issue with a broad diagnosis list like this is specificity. Aetna isn't approving teduglutide for all 37 of these codes unconditionally. The diagnosis must support the clinical rationale for this specific drug. Document why teduglutide — not an alternative therapy — is medically necessary for that patient's presentation.

Precertification requests go to:

Aetna Teduglutide Exclusions and Non-Covered Indications

The policy data does not enumerate a formal exclusions list under CPB 0849. That doesn't mean everything gets covered.

Diagnoses not on the 37-code list won't support a precertification approval. If a provider wants to use teduglutide for a condition outside this list, expect a medical necessity denial without a strong clinical exception argument. The breadth of the ICD-10 list does cover most plausible use cases, but outlier situations — off-label uses not reflected in the diagnosis table — will face scrutiny.

Medicare is explicitly carved out of this policy. Commercial CPB 0849 billing guidelines don't govern Medicare claims. Route those to the appropriate Part B criteria.

Coverage Indications at a Glance

Aetna Teduglutide Billing Guidelines and Action Items 2025

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

The policy data for CPB 0849 does not list specific CPT or HCPCS billing codes for teduglutide (Gattex). Teduglutide is typically billed using the appropriate specialty pharmacy or drug administration codes depending on the site of service and plan type. Confirm the correct billing code with Aetna directly during precertification, and document that confirmation in the patient file.

Key ICD-10-CM Diagnosis Codes