Mepolizumab (Nucala) — CPB 0897 | AETNA Coverage Update

Aetna modified CPB 0897 for mepolizumab (Nucala), effective January 5, 2026. Here's what billing teams need to know before submitting claims under J2182.

Aetna, a CVS Health company, updated its Nucala coverage policy under CPB 0897 Aetna system, adding new prescriber specialty requirements and refining medical necessity criteria across five indications. The primary billing code is J2182 (injection, mepolizumab, 1 mg). Administration is billed under CPT 96372. If your practice treats severe asthma, eosinophilic granulomatosis with polyangiitis (EGPA), hypereosinophilic syndrome (HES), chronic rhinosinusitis with nasal polyposis (CRSwNP), or COPD, this change touches your prior authorization workflow and your claim denial exposure.

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Quick-Reference Table

Field	Detail Copy
Payer	Aetna, a CVS Health company
Policy	Mepolizumab (Nucala) — CPB 0897
Policy Code	CPB 0897
Change Type	Modified
Effective Date	January 5, 2026
Impact Level	High
Specialties Affected	Allergist/immunologist, pulmonologist, otolaryngologist
Key Action	Confirm prescriber specialty matches the indication before submitting precertification for J2182

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Aetna Mepolizumab Coverage Criteria and Medical Necessity Requirements 2026

The Aetna mepolizumab coverage policy requires precertification for every claim. Call (866) 752-7021 or fax (888) 267-3277 to precertify. Statement of Medical Necessity forms are available through Aetna's Specialty Pharmacy Precertification portal.

Precertification isn't optional here — it's a hard requirement for all participating providers and members in applicable plan designs. Missing it means a claim denial before anyone looks at the clinical record.

Aetna also applies a site-of-care utilization management policy to Nucala. Before you bill for an office-based infusion or self-injection, check Aetna's Site of Care for Specialty Drug Infusions policy. This is a separate layer on top of the CPB 0897 coverage policy, and it can affect reimbursement even when the clinical criteria are met.

Asthma Medical Necessity Criteria

Aetna covers mepolizumab for asthma in members 6 years of age or older. There are two paths to approval.

The first path: the member previously received a biologic drug indicated for asthma (such as Dupixent or Cinqair) in the past year. That prior biologic use satisfies the criteria without additional clinical documentation.

The second path is more involved. The member must have a baseline blood eosinophil count of at least 150 cells per microliter — or be dependent on systemic corticosteroids. They must also show uncontrolled asthma in the past year, defined as at least one of: two or more exacerbations requiring oral or injectable corticosteroids, one hospitalization or emergency visit for asthma, or poor symptom control (frequent symptoms, limited activity, night waking).

Beyond that, the member must have inadequate control despite both a high-dose inhaled corticosteroid and an additional controller agent — long-acting beta2-agonist, long-acting muscarinic antagonist, leukotriene modifier, or sustained-release theophylline. And the member must continue those maintenance treatments alongside Nucala. Document all of this before submitting the prior authorization request.

Prescriber requirement for asthma: allergist/immunologist or pulmonologist.

EGPA Medical Necessity Criteria

For eosinophilic granulomatosis with polyangiitis, coverage applies to members 18 years of age or older. Like asthma, there's a fast-track path: prior biologic use indicated for EGPA (such as Fasenra) in the past year.

Otherwise, the member must have a history or current eosinophil count above 1,000 cells per microliter, plus additional criteria consistent with active or relapsing EGPA. Prescriber requirement: allergist/immunologist or pulmonologist.

HES Medical Necessity Criteria

Hypereosinophilic syndrome coverage comes with hard exclusions (detailed in the next section). For eligible members, criteria require confirmed HES diagnosis with appropriate eosinophil thresholds. ICD-10 codes D72.110 through D72.119 map to the HES indications.

CRSwNP Medical Necessity Criteria

For chronic rhinosinusitis with nasal polyposis, coverage applies to members 18 years of age or older. Relevant workup codes under this policy include CPT 31231 (nasal endoscopy, diagnostic) and CPT 70486–70488 (CT of the maxillofacial area). These codes show up in the policy because they're part of the diagnostic workup Aetna expects to see documented. Prescriber requirement: allergist/immunologist or otolaryngologist.

ICD-10 codes J32.0 through J32.2 (chronic sinusitis with nasal polyposis, age 18 and older) are the relevant diagnosis codes here.

COPD Medical Necessity Criteria

The COPD indication is the newest addition in recent Nucala coverage policy updates. Prescriber requirement for COPD: pulmonologist or allergist/immunologist. This is the only indication where otolaryngologist is not an accepted prescriber specialty.

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Aetna Mepolizumab Exclusions and Non-Covered Indications

HES is where the exclusions are most detailed — and most likely to create claim denials.

Aetna excludes mepolizumab for HES when the syndrome is secondary to a non-hematologic cause. That list includes drug hypersensitivity, parasitic helminth infection, HIV infection (ICD-10 B20), and non-hematologic malignancy. Aetna also excludes FIP1L1-PDGFRA kinase-positive HES from coverage.

The HES exclusion list is specific enough that you need to look at the underlying cause of the eosinophilia, not just the eosinophil count. A member with elevated eosinophils and a helminth infection (ICD-10 codes B81.0–B81.8 or B83.0–B83.9) won't qualify. Neither will a member with HIV. Document the HES etiology explicitly in the precertification request — not just the diagnosis code.

FIP1L1-PDGFRA kinase-positive HES is a distinct molecular subtype. If the genetic test hasn't been done or isn't documented, you're creating prior authorization risk. Make sure the clinical record confirms absence of this marker before submitting.

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Coverage Indications at a Glance

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Aetna Mepolizumab Billing Guidelines and Action Items 2026

Copy Action Items

If your practice has a mixed payer population or you're seeing multiple Nucala indications across your patient panel, loop in your compliance officer before the effective date of January 5, 2026. The prescriber specialty rules and HES exclusions are specific enough that an internal audit of pending prior auths is worth doing now.

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CPT, HCPCS, and ICD-10 Codes for Mepolizumab Under CPB 0897

Covered HCPCS Code (When Selection Criteria Are Met)

Code	Type	Description Copy
J2182	HCPCS	Injection, mepolizumab, 1 mg

CPT Codes Related to CPB 0897

Not Covered in Combination with Mepolizumab

Code	Type	Description	Reason Copy
J2357	HCPCS	Injection, omalizumab, 5 mg	Not covered in combination with mepolizumab (Nucala)
J2786	HCPCS	Injection, reslizumab, 1 mg	Not covered in combination with mepolizumab (Nucala)

Supporting HCPCS Codes (Corticosteroids and Inhaled Agents Referenced in Policy)

Key ICD-10-CM Diagnosis Codes

The full ICD-10 code set for CPB 0897 includes 139 codes. Review the complete list at the Aetna CPB 0897 source document.

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