Elbow Arthroplasty — CPB 0857 | AETNA Coverage Update

Aetna modified CPB 0857 for elbow arthroplasty, effective December 10, 2025. Here's what billing teams need to do.

Aetna, a CVS Health company, updated its elbow arthroplasty coverage policy under CPB 0857 in Aetna's clinical policy bulletin system. This policy governs eight CPT codes — 24360, 24361, 24362, 24363, 24365, 24366, 24370, and 24371 — and draws hard lines around what gets covered, what gets denied, and what Aetna considers experimental. If your practice bills elbow arthroplasty for Aetna members, the criteria in this update determine whether your claims pay or not.

Quick-Reference Table

Aetna Elbow Arthroplasty Coverage Criteria and Medical Necessity Requirements 2025

The Aetna elbow arthroplasty coverage policy under CPB 0857 sets four specific pathways to medical necessity for total elbow arthroplasty. If your patient doesn't fit one of these four boxes, the claim won't survive a medical necessity review.

Pathway 1: Displaced intra-articular distal humerus fracture — the fracture must be osteoporotic or not amenable to internal fixation. This is a critical threshold. If the fracture is reconstructible, Aetna won't cover total elbow arthroplasty (CPT 24363). Document clearly that internal fixation is not viable or that bone quality precludes it.

Pathway 2: Elbow pain unresponsive to medical therapy — two things must be true. First, radiographs must show destruction of articular cartilage or gross deformity. Second, the patient must be unable to use the extremity for activities of daily living because of pain, motion loss, or instability. You need both. One without the other fails the test.

Pathway 3: Elbow ankylosis after sepsis or trauma — ICD-10 codes M24.621 through M24.629 cover the ankylosis diagnoses Aetna accepts here. Make sure the record documents the causal relationship to prior sepsis or trauma.

Pathway 4: Salvage or revision of a failed implant — CPT codes 24370 (revision, humeral or ulnar component) and 24371 (revision, humeral and ulnar component) are covered for this indication. Use ICD-10 codes T84.410+ through T84.498+ for mechanical complications and T84.50x+ or T84.559+ for infection and inflammatory reaction related to the prior prosthesis.

For radial head procedures, CPT 24365 and 24366 (arthroplasty, radial head, with implant) are covered for unreconstructible comminuted radial head fractures. Aetna explicitly notes that silicone implants don't hold up to wear — so metal implants are the standard here. ICD-10 codes S52.121+ through S52.126+ cover fractures of the head of the radius.

The corticosteroid contraindication is the rule most likely to burn you. Aetna considers elbow arthroplasty not medically necessary for any patient who received a corticosteroid injection into the joint within 12 weeks of the planned procedure. This isn't a soft guideline — it's a hard contraindication. If the injection is in the record and the surgery is within that 12-week window, the claim will get denied. Flag this in your pre-authorization checklist before the case is scheduled.

The Aetna elbow arthroplasty coverage policy does not specify prior authorization requirements within CPB 0857 itself. That said, elbow arthroplasty is a surgical procedure with meaningful reimbursement exposure. Verify prior auth requirements for CPT 24363 and the revision codes through Aetna's plan-specific requirements before the procedure date. Don't assume a policy bulletin silence on prior authorization means auth isn't required.

Aetna Elbow Arthroplasty Exclusions and Non-Covered Indications

Aetna draws three clear lines in CPB 0857 around procedures it considers experimental and investigational. These are claim denials waiting to happen if your clinical team isn't aligned with the payer's definitions.

Elbow hemiarthroplasty for humerus fractures is experimental. Full stop. If your surgeon performs a hemiarthroplasty on a distal humerus fracture and you bill it, Aetna will deny it as not established. There is no coverage pathway for this indication under CPB 0857.

Total elbow arthroplasty (CPT 24363) for reconstructible comminuted radial head fractures is experimental. Aetna covers metal radial head arthroplasty (CPT 24365, 24366) for unreconstructible fractures — but if the fracture is reconstructible, total elbow arthroplasty isn't covered. The distinction between reconstructible and unreconstructible must be documented explicitly in the operative report and pre-authorization request.

Total elbow arthroplasty for osteoarthritis secondary to fracture is also experimental. This one is subtle and worth discussing with your compliance officer. ICD-10 codes M19.221 through M19.229 cover secondary osteoarthritis of the elbow. Aetna includes these codes in the policy's ICD-10 table — but labels total elbow arthroplasty for this indication as experimental. The codes appear in the covered list, but the clinical pathway for secondary post-fracture OA leading to total elbow arthroplasty is not a covered route under this policy. If you have cases where the primary diagnosis is M19.22x, confirm with your billing consultant or compliance officer whether the claim will hold before submitting.

Coverage Indications at a Glance

Aetna Elbow Arthroplasty Billing Guidelines and Action Items 2025

CPT, HCPCS, and ICD-10 Codes for Elbow Arthroplasty Under CPB 0857

Covered CPT Codes (When Selection Criteria Are Met)

Key ICD-10-CM Diagnosis Codes