Romosozumab-aqqg (Evenity) — CPB 0954 | AETNA Coverage Update

Aetna modified CPB 0954 for romosozumab-aqqg (Evenity), effective February 21, 2026. Here's what billing teams need to know before submitting claims.

Aetna, a CVS Health company, updated its Evenity coverage policy under CPB 0954 Aetna's clinical policy bulletin system, tightening the criteria for initial approval and continuation of therapy for postmenopausal osteoporosis. The primary billing code at stake is J3111 (injection, romosozumab-aqqg, 1 mg), administered under CPT 96372. If your practice bills J3111 and your patients don't meet the revised criteria, expect claim denial.

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Quick-Reference Table

Field	Detail Copy
Payer	Aetna, a CVS Health company
Policy	Romosozumab-aqqg (Evenity) — CPB 0954
Policy Code	CPB 0954
Change Type	Modified
Effective Date	2026-02-21
Impact Level	High
Specialties Affected	Endocrinology, Rheumatology, Primary Care, Obstetrics/Gynecology
Key Action	Verify T-score documentation, FRAX scores, and prior therapy history before submitting precertification for J3111

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Aetna Romosozumab-aqqg Coverage Criteria and Medical Necessity Requirements 2026

The Aetna romosozumab-aqqg coverage policy under CPB 0954 requires precertification for all participating providers and members on applicable plan designs. Call (866) 752-7021 or fax (888) 267-3277 to start that process. Don't skip this step — billing J3111 without prior authorization is a fast path to denial.

To meet medical necessity under this coverage policy, your patient must have postmenopausal osteoporosis. That's the only approved indication. Everything else is experimental.

Aetna approves Evenity under two distinct pathways for initial approval.

Pathway 1 — Fragility Fracture History

The member has a documented history of fragility fractures. These are low-trauma fractures from forces equivalent to a fall from standing height. ICD-10 codes M80.00xA through M80.08xS (age-related osteoporosis with current pathological fracture) and the fracture-of-femur range S72.001A through S72.92XS are your primary diagnosis anchors here.

Pathway 2 — T-Score and FRAX-Based Criteria

The member has a pre-treatment T-score ≤ -2.5, or has osteopenia (T-score between -1 and -2.5) with a high FRAX probability. If your patient falls into the osteopenia range, the FRAX documentation is not optional — it's required. Without it, the precertification will fail.

Under Pathway 2, the member must also meet at least one of three sub-criteria:

#	Covered Indication Copy
1	Very high fracture risk indicators — advanced age, frailty, glucocorticoid use, T-score ≤ -3, or increased fall risk. ICD-10 M81.0 (age-related osteoporosis without current pathological fracture) applies here.
2	Inadequate response or intolerance to injectable osteoporosis therapy — this means prior failure of zoledronic acid (Reclast, J3489), teriparatide (Forteo, J3110), a denosumab product (Prolia and biosimilars — J0897, Q5157, Q5158, Q5159), or abaloparatide (Tymlos). You need documented prior therapy attempts in the chart.
3	Inadequate response or intolerance to oral bisphosphonate therapy — no specific HCPCS code here, but the medical record must show prior bisphosphonate failure. Chart documentation carries the weight.

Romosozumab-aqqg billing without this prior therapy documentation is a denial waiting to happen. Get the medical records in order before you submit.

For continuation of therapy, Aetna requires the member to still meet all initial criteria and to have received fewer than 12 monthly doses. Evenity's treatment course is 12 monthly injections. Once a member hits 12 doses, the coverage stops under this policy — full stop.

This policy applies to commercial plans only. For Medicare criteria, Aetna directs you to its Medicare Part B step therapy requirements, which are separate.

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Aetna Romosozumab-aqqg Exclusions and Non-Covered Indications

Aetna is explicit: all indications other than postmenopausal osteoporosis are experimental, investigational, or unproven.

The ICD-10 list attached to this policy includes codes for rheumatoid arthritis (M05.00–M05.879 and M06.00–M06.879), renal osteodystrophy (N25.0), osteogenesis imperfecta (Q78.0), Hajdu-Cheney syndrome (Q89.81–Q89.89), and pregnancy/lactation-associated osteoporosis (O92.79). These codes appear in the policy's code set, but glucocorticoid-induced osteoporosis is explicitly noted as not covered under M81.8.

The real issue here is that some of these diagnoses might look plausible to a clinician ordering Evenity for bone loss. Your billing team needs to flag any claim where the primary diagnosis falls outside postmenopausal osteoporosis. If the provider documents a secondary condition like rheumatoid arthritis and the primary indication isn't postmenopausal osteoporosis, the claim won't survive review.

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Coverage Indications at a Glance

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Aetna Romosozumab-aqqg Billing Guidelines and Action Items 2026

These are the steps your billing and clinical documentation teams need to take now — before the February 21, 2026 effective date has passed you by.

Copy Action Items

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CPT, HCPCS, and ICD-10 Codes for Romosozumab-aqqg Under CPB 0954

Covered HCPCS and CPT Codes (When Selection Criteria Are Met)

Code	Type	Description Copy
J3111	HCPCS	Injection, romosozumab-aqqg, 1 mg
96372	CPT	Therapeutic, prophylactic, or diagnostic injection; subcutaneous or intramuscular

Prior Therapy Codes (Required for Pathway 2 Documentation)

These codes represent the injectable therapies a member must have tried and failed before Evenity qualifies under Pathway 2. They appear on the prior claim history, not on the Evenity claim itself.

Key ICD-10-CM Diagnosis Codes

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