Aetna modified CPB 0928 for optical coherence tomography of the head and neck, effective January 5, 2026. Here's what billing teams need to do.
Aetna, a CVS Health company, updated CPB 0928 — its coverage policy governing optical coherence tomography (OCT) of the head and neck. This revision expands the list of procedures the payer considers experimental, investigational, or unproven. If your team bills CPT codes 0485T, 0486T, 92133, or 92134 for head and neck indications, or works in ENT, otolaryngology, oncology, ophthalmology, or dermatology, this update touches your claims.
Quick-Reference Table
| Field | Detail |
|---|---|
| Payer | Aetna, a CVS Health company |
| Policy | Optical Coherence Tomography of the Head and Neck |
| Policy Code | CPB 0928 |
| Change Type | Modified |
| Effective Date | January 5, 2026 |
| Impact Level | Medium |
| Specialties Affected | ENT / Otolaryngology, Head & Neck Surgery, Ophthalmology, Dermatology, Radiation Oncology, Oral Surgery |
| Key Action | Audit any claims pairing CPT 0485T, 0486T, 92133, or 92134 with the ICD-10 codes below — all listed indications are now explicitly non-covered |
Aetna OCT Head and Neck Coverage Criteria and Medical Necessity Requirements 2026
Here's the short version: CPB 0928 has no covered indications for OCT of the head and neck. Every indication addressed in this policy is classified as experimental, investigational, or unproven. There are no medical necessity criteria to satisfy because Aetna does not recognize any head and neck OCT use as established or reimbursable under this bulletin.
This is a broad non-coverage policy, not a criteria-heavy one. The source policy does not address prior authorization. Billing teams should consult Aetna's prior authorization lookup tool for current requirements.
The real issue is that several of these uses are clinically active and some practitioners treat them as routine. Aetna's position is that the clinical evidence hasn't caught up. Your billing team should not assume payer silence on a code means the service is covered.
For retinal OCT, which is covered, look to CPB 0344. For anterior segment OCT, look to CPB 0749. For intravascular OCT, CPB 0829 applies. CPB 0928 is strictly head and neck — don't confuse the policy scope when routing claims.
Aetna OCT Head and Neck Exclusions and Non-Covered Indications
Aetna classifies every head and neck OCT application in this policy as experimental or unproven. That's 10 distinct procedures across multiple specialties. This isn't a short list of edge cases — it covers imaging used in ENT, oncologic surgery, ophthalmology, and dermatology.
Here's each excluded indication, stated plainly:
1. Annual OCT for thyroid ophthalmopathy follow-up after orbital decompression
Aetna does not cover OCT imaging for follow-up of thyroid eye disease post-surgery, including thyroid-associated ophthalmopathy coded under E05.0 and E05.1. The relevant CPT codes here are 92133 and 92134.
2. Dynamic OCT for actinic keratosis evaluation
Dynamic OCT used for evaluating actinic keratosis (L57.0) is not covered. If your dermatology team is using this for skin lesion assessment, expect a claim denial under Aetna.
3. Endoscopic OCT for tympanoplasty evaluation
OCT used to evaluate tympanoplasty outcomes is not covered. This maps to tympanic membrane disorder codes in the H73 range.
4. Intra-operative wide-field OCT for deep margin analysis in head and neck surgery
Wide-field intraoperative OCT for margin assessment during head and neck cancer surgery — coded with CPT 0485T or 0486T — is not covered. Head and neck cancer diagnosis codes run from C1 through C14.
5. OCT for middle ear assessment and management
Any OCT used for middle ear evaluation is experimental. This includes CPT 0485T and 0486T for middle ear imaging and the OCT otoscope devices discussed below.
6. OCT for oral cancer diagnosis
OCT used to diagnose oral cancerous lesions is not covered, including encounters coded Z12.81 (oral cavity cancer screening). This matters for oral surgery and head and neck oncology practices.
7. OCT for voice disorder evaluation
OCT used in evaluating voice disorders (R47.1 through R47.9) is not covered. This affects laryngology practices.
8. OCT for monitoring radiation-induced skin changes
Monitoring radiation dermatitis or radiodermatitis using OCT — coded L58.0 through L58.9 and L59.0 through L59.9 — is not covered. Radiation oncology practices managing head and neck cancer patients should flag this.
9. OCTA for giant cell arteritis and thyroid-associated ophthalmopathy
OCT angiography (OCTA) for detecting subclinical low perfusion features in patients with giant cell arteritis (M31.5, M31.6) without active ocular involvement is not covered. OCTA for thyroid-associated ophthalmopathy is also excluded.
10. OCT otoscope devices for tympanic membrane and middle ear imaging
Aetna explicitly calls out the OtoSight Middle Ear Scope and TOMi Scope by name. These devices — billed under CPT 0485T and 0486T — are not covered for imaging tympanic membrane or middle ear pathology (H73.891–H73.899, H74.8X1–H74.8X9).
Coverage Indications at a Glance
| Indication | Status | Relevant CPT Codes | Key ICD-10 Codes | Notes |
|---|---|---|---|---|
| Annual OCT for thyroid ophthalmopathy post-orbital decompression | Experimental | 92133, 92134 | E05.0, E05.1 | Not covered; no prior auth pathway |
| Dynamic OCT for actinic keratosis | Experimental | — | L57.0 | Not covered |
| Endoscopic OCT for tympanoplasty evaluation | Experimental | — | H73.891–H73.899 | Not covered; CPT codes not explicitly mapped to this indication in source policy |
| Intra-operative wide-field OCT for head/neck surgical margins | Experimental | 0485T, 0486T | C1–C14 | Not covered |
| OCT for middle ear assessment | Experimental | 0485T, 0486T | H73–H74 range | Not covered |
| OCT for oral cancer diagnosis | Experimental | — | Z12.81 | Not covered |
| OCT for voice disorder evaluation | Experimental | — | R47.1–R47.9 | Not covered |
| OCT for radiation-induced skin monitoring | Experimental | — | L58.0–L59.9 | Not covered |
| OCTA for giant cell arteritis (subclinical, no ocular involvement) | Experimental | — | M31.5, M31.6 | Not covered |
| OCTA for thyroid-associated ophthalmopathy | Experimental | — | E05.0, E05.1 | Not covered |
| OCT otoscope (OtoSight, TOMi Scope) for tympanic membrane/middle ear | Experimental | 0485T, 0486T | H73.891–H73.899, H74.8X1–H74.8X9 | Device-specific exclusion; named explicitly |
Aetna OCT Head and Neck Billing Guidelines and Action Items 2026
This policy is fully in effect as of January 5, 2026. If your team hasn't already acted on the effective date, do it now.
| # | Action Item |
|---|---|
| 1 | Pull any pending or recent claims with CPT 0485T or 0486T paired with head and neck diagnosis codes. Check for denials already issued and assess whether those claims were submitted with ICD-10 codes in the C1–C14, H73, H74, or R47 ranges. This is your fastest exposure check. |
| 2 | Flag CPT 92133 and 92134 when billed for thyroid-associated ophthalmopathy. These codes are covered for retinal indications under CPB 0344 — but when the clinical context is thyroid eye disease or orbital decompression follow-up, Aetna treats them as non-covered under CPB 0928. The same code, different clinical context, different result. |
| 3 | Remove OCT otoscope services from your Aetna charge capture. If your ENT practice uses the OtoSight Middle Ear Scope or TOMi Scope and bills CPT 0485T or 0486T to Aetna, stop billing those to the payer. Collect from the patient under a cash-pay or ABN structure, or don't offer the service without discussing patient responsibility first. |
| 4 | Issue Advance Beneficiary Notices (ABNs) or equivalent patient financial responsibility disclosures before performing any of the 10 excluded procedures on Aetna-insured patients. For head and neck cancer patients on radiation therapy, oral surgery patients, and laryngology patients especially — this matters before service, not after. |
| 5 | Audit your dermatology and radiation oncology workflows. OCT for radiation-induced skin changes (L58.0–L59.9) and dynamic OCT for actinic keratosis (L57.0) are non-covered. If your radiation oncology team added this monitoring protocol this year, they need to know it won't pay under Aetna. |
| 6 | Cross-check claims against related CPB policies before billing. If your team is uncertain whether a claim belongs under CPB 0928 or one of the related bulletins — CPB 0344 for retinal OCT, CPB 0749 for anterior segment, CPB 0829 for intravascular OCT, or CPB 0886 for solid tumor OCT — resolve that before submission. Wrong policy mapping is a fast path to a claim denial that takes months to appeal. |
| 7 | Talk to your compliance officer if your practice has been billing any of these excluded indications routinely. This isn't a situation where you appeal and win — it's a situation where continued billing could create a pattern that triggers a refund demand. Get ahead of it. |
| Previous Version | Current Version |
|---|---|
| Coverage is considered experimental and investigational for all indications | Coverage is considered medically necessary when specific criteria are met |
| Prior authorization is not required | Prior authorization is required for initial treatment |
| Documentation must include clinical history | Documentation must include clinical history |
| Re-review every 24 months | Re-review every 12 months with updated clinical documentation |
CPT, HCPCS, and ICD-10 Codes for OCT Head and Neck Under CPB 0928
Not Covered / Experimental CPT Codes
| Code | Type | Description | Indication Context |
|---|---|---|---|
| 0485T | CPT | OCT of middle ear, with interpretation and report | Middle ear assessment, OCT otoscope, tympanic membrane imaging, intra-operative head/neck |
| 0486T | CPT | OCT of middle ear, with interpretation and report | Middle ear assessment, OCT otoscope, tympanic membrane imaging, intra-operative head/neck |
| 92133 | CPT | Scanning computerized ophthalmic diagnostic imaging, posterior segment, with interpretation and report | Thyroid ophthalmopathy follow-up; covered for retinal indications under CPB 0344 — not under CPB 0928 |
| 92134 | CPT | Scanning computerized ophthalmic diagnostic imaging, posterior segment (retina), with interpretation and report | Same as above |
Key ICD-10-CM Diagnosis Codes
| Code | Description |
|---|---|
| C1–C9 | Malignant neoplasm of lip, oral cavity, and pharynx (head and neck cancer) |
| C10 | Malignant neoplasm of oropharynx |
| C11 | Malignant neoplasm of nasopharynx |
| C12 | Malignant neoplasm of pyriform sinus |
| C13 | Malignant neoplasm of hypopharynx |
| C14 | Malignant neoplasm of other ill-defined sites in the lip, oral cavity, and pharynx |
| E05.0 | Thyrotoxicosis with diffuse goiter (thyroid-associated ophthalmopathy) |
| E05.1 | Thyrotoxicosis with diffuse goiter (thyroid-associated ophthalmopathy) |
| H73.891–H73.899 | Other specified disorders of tympanic membrane |
| H74.8X1–H74.8X9 | Other specified disorders of middle ear and mastoid |
| L57.0 | Actinic keratosis |
| L58.0–L58.9 | Radiodermatitis (radiation-induced skin changes) |
| L59.0–L59.9 | Other disorders of skin and subcutaneous tissue related to radiation |
| M31.5 | Giant cell arteritis |
| M31.6 | Other giant cell arteritis |
| R47.1–R47.9 | Voice and resonance disorders |
| Z12.81 | Encounter for screening for malignant neoplasm of oral cavity |
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