Inebilizumab-cdon (Uplizna) — CPB 0975 | AETNA Coverage Update

Aetna modified CPB 0975 for inebilizumab-cdon (Uplizna), effective December 20, 2025. Here's what billing teams need to do.

Aetna, a CVS Health company, updated its Uplizna coverage policy under CPB 0975 to add IgG4-related disease (IgG4-RD) as a covered indication alongside the existing neuromyelitis optica spectrum disorder (NMOSD) approval. The primary drug billing code is HCPCS J1823, billed alongside infusion administration codes 96365–96368. If your practice or infusion center treats either condition, this expansion changes your prior authorization workflow and documentation requirements immediately.

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Quick-Reference Table

Field	Detail Copy
Payer	Aetna, a CVS Health company
Policy	Inebilizumab-cdon (Uplizna) — CPB 0975
Policy Code	CPB 0975
Change Type	Modified
Effective Date	December 20, 2025
Impact Level	High
Specialties Affected	Neurology, Rheumatology, Infusion Centers, Specialty Pharmacy
Key Action	Update prior authorization workflows for IgG4-RD patients and confirm ICD-10 D89.84 is mapped in your charge capture before billing J1823

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Aetna Inebilizumab-cdon (Uplizna) Coverage Criteria and Medical Necessity Requirements 2025

The real story in this update is the IgG4-RD addition. NMOSD coverage was already established under CPB 0975. The December 20, 2025 effective date brings IgG4-RD into the fold — but with a tighter, more layered set of criteria than the NMOSD pathway. Both indications require precertification before you bill J1823.

NMOSD Coverage Criteria

For neuromyelitis optica spectrum disorder (ICD-10 G36.0), Aetna's coverage policy requires all three of the following:

#	Covered Indication Copy
1	The member tests anti-aquaporin-4 (AQP4) antibody positive. Aetna lists CPT codes 86051, 86052, and 86053 as the relevant testing codes — ELISA, cell-based immunofluorescence assay, and flow cytometry, respectively. You need this documentation in the file before submitting for prior auth.
2	The member shows at least one core clinical characteristic: optic neuritis, acute myelitis, area postrema syndrome, acute brainstem syndrome, symptomatic narcolepsy or acute diencephalic syndrome with NMOSD-typical MRI lesions, or symptomatic cerebral syndrome with NMOSD-typical brain lesions.
3	The member will not receive Uplizna alongside other biologics for NMOSD. Combination biologic therapy is an automatic denial trigger.

For continuation of therapy under NMOSD, you also need documented positive response — specifically, reduction in relapse frequency. "Stable" without that context won't carry the claim.

IgG4-Related Disease Coverage Criteria

For IgG4-RD (ICD-10 D89.84), the medical necessity bar is higher. All four of the following must be met:

That four-week glucocorticoid window is the piece most likely to trip up your prior auth submissions. If the flare occurred five weeks ago and the notes don't show active treatment within four weeks, Aetna will deny on criteria. Make sure your clinical team documents the glucocorticoid initiation date explicitly.

For IgG4-RD continuation, Aetna requires no evidence of unacceptable toxicity and documented positive response — framed as reduction in IgG4-RD flares.

Prior Authorization and Site of Care

Precertification is required for all Aetna participating providers and members in applicable plan designs. Call (866) 752-7021 or fax (888) 267-3277. Statement of Medical Necessity forms are available through Aetna's Specialty Pharmacy Precertification page.

Aetna's Site of Care Utilization Management Policy also applies to Uplizna infusions. This matters for your reimbursement calculation — where the infusion happens affects which facility fees and infusion codes apply. Check the site-of-service policy before you assume your current infusion center setup is approved.

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Aetna Inebilizumab-cdon (Uplizna) Exclusions and Non-Covered Indications

Aetna's position is direct: all indications for Uplizna other than NMOSD and IgG4-RD are considered experimental, investigational, or unproven. There is no off-label pathway listed.

If your clinical team wants to use Uplizna for any condition outside G36.0 or D89.84, expect a denial. Don't submit without a peer-to-peer scheduled and a strong appeal argument — and talk to your compliance officer before going that route.

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Coverage Indications at a Glance

Indication	Status	Relevant Codes	Notes Copy
Neuromyelitis optica spectrum disorder (NMOSD)	Covered	G36.0, J1823, 96365–96368, 86051, 86052, 86053	AQP4 antibody positive required; no concurrent biologics; prior auth required
IgG4-related disease (IgG4-RD)	Covered	D89.84, J1823, 96365–96368	Active flare with glucocorticoid use within 4 weeks; ≥2 organ involvement history; prior auth required
All other indications	Experimental / Not Covered	—	Aetna considers all other uses experimental, investigational, or unproven

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Aetna Uplizna Billing Guidelines and Action Items 2025

This change is effective December 20, 2025. If you're already billing J1823 for NMOSD patients, your workflow doesn't change — but you need to verify that AQP4 antibody test documentation (CPT 86051, 86052, or 86053) is in the authorization file. If it's not, pull it now before your next reauthorization comes due.

For IgG4-RD, this is a new indication with no prior workflow at your practice. Build the process from scratch before you submit your first claim.

Copy Action Items

If your practice sees a significant volume of either NMOSD or IgG4-RD patients, loop in your billing consultant before December 20, 2025 passes without a workflow update. The IgG4-RD criteria are detailed enough that a single missed element can generate a pattern of denials.

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CPT, HCPCS, and ICD-10 Codes for Inebilizumab-cdon (Uplizna) Under CPB 0975

HCPCS Code Covered When Selection Criteria Are Met

Code	Type	Description Copy
J1823	HCPCS	Injection, inebilizumab-cdon, 1 mg

CPT Codes Related to CPB 0975

Key ICD-10-CM Diagnosis Codes

Code	Description Copy
G36.0	Neuromyelitis optica [Devic]
D89.84	IgG4-related disease

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