Aducanumab-avwa (Aduhelm) — CPB 0996 | AETNA Coverage Update

Aetna modified CPB 0996 for aducanumab-avwa (Aduhelm), effective December 10, 2025. Here's what billing teams need to know before submitting claims.

Aetna, a CVS Health company, updated its Aduhelm coverage policy under CPB 0996, tightening medical necessity criteria and exclusion rules for commercial plan members. The policy covers J0172 (injection, aducanumab-avwa, 2 mg) and ties coverage to a specific diagnostic workup — including PET imaging (CPT 78811, 78814) and lumbar puncture (CPT 62270). If your practice bills for anti-amyloid therapy in Alzheimer's disease patients, this update changes what documentation you need before submitting a claim.

---

Quick-Reference Table

Field	Detail Copy
Payer	Aetna
Policy	Aducanumab-avwa (Aduhelm) — CPB 0996
Policy Code	CPB 0996
Change Type	Modified
Effective Date	December 10, 2025
Impact Level	High
Specialties Affected	Neurology, Geriatrics, Psychiatry, Neuropsychiatry
Key Action	Verify full documentation — amyloid confirmation, cognitive scoring, MRI safety clearance — before submitting J0172 claims

---

Aetna Aduhelm Coverage Criteria and Medical Necessity Requirements 2025

Aetna's Aduhelm coverage policy under CPB 0996 requires prior authorization for every member on every applicable commercial plan. Call (866) 752-7021 or fax (866) 267-3277 to precertify. Submit a Statement of Medical Necessity (SMN) form through Aetna's Specialty Pharmacy Precertification portal.

The policy also applies Aetna's Site of Care Utilization Management Policy for specialty drug infusions. That means your billing team needs to confirm the infusion site meets Aetna's requirements before you administer or bill — reimbursement can be denied solely on site-of-service grounds, even if clinical criteria are met.

Who Qualifies: Age and Diagnosis

To meet medical necessity, the member must be 50 years of age or older. Members under 50 qualify only with a documented genetic mutation in APP (CPT 81406), PSEN1 (CPT 81405), or PSEN2, or other clinical documentation supporting early-onset AD.

The diagnosis must be mild cognitive impairment due to Alzheimer's disease or mild AD dementia. Moderate or severe AD does not qualify. Code G31.84 (mild cognitive impairment of uncertain or unknown etiology, mapped here to AD) is the key ICD-10 anchor alongside G30.x Alzheimer's disease codes.

Cognitive Scoring Requirements

The member must show objective evidence of cognitive impairment at baseline and score within specific ranges on at least one of the following tools:

#	Covered Indication Copy
1	CDR-Global Score of 0.5 or 1
2	MMSE score of 21–30
3	MoCA score of ≥16

Document the specific score and the specific tool used. Aetna will not accept a general reference to "cognitive testing." The score must be in the record and tied to a named assessment.

Amyloid Confirmation: PET or CSF

This is where a lot of claims will fall apart. The member must have amyloid pathology confirmed by either a PET scan or a lumbar puncture with CSF analysis.

For PET, bill CPT 78811 (limited area PET) or 78814 (PET/CT). Radiopharmaceuticals A9586 (florbetapir F-18) and Q9982 (flutemetamol F-18) are in the policy. For CSF confirmation via lumbar puncture (CPT 62270), Aetna accepts any of these findings:

CPT 0445U covers the ECLIA-based beta-amyloid and P-tau181 assay. If your lab uses this code, confirm results meet one of the CSF criteria above before treating it as confirmatory documentation.

MRI Safety Check

Per the full policy text, the member must have a recent MRI of the brain before treatment starts. CPT 70551 (without contrast), 70552 (with contrast), or 70553 (without then with contrast) covers this procedure. Because the available policy summary is truncated, verify the complete MRI requirement language in the untruncated CPB 0996 document before relying on this criterion — and confirm exactly what documentation Aetna requires in the prior authorization package.

The clinical rationale is clear regardless: Aduhelm carries risk of amyloid-related imaging abnormalities (ARIA), and pre-treatment MRI is standard practice for this drug class. Talk to your compliance officer if you have questions about how to document this requirement under the current policy language.

---

Aetna Aduhelm Exclusions and Non-Covered Indications

Aetna's coverage policy is explicit: five categories result in automatic denial. Train your prior auth team on all of them.

Excluded conditions:

The combination-use exclusion is a billing team issue, not just a clinical one. If a member switches therapies, document the stop date of the prior agent before prior authorization for Aduhelm goes through. A claim denial on this basis is hard to overturn without clear transition records.

---

Coverage Indications at a Glance

---

Aetna Aduhelm Billing Guidelines and Action Items 2025

The effective date is December 10, 2025. If you bill J0172 for Aduhelm under commercial Aetna plans, act on these steps now.

Copy Action Items

---

CPT, HCPCS, and ICD-10 Codes for Aduhelm Under CPB 0996

Covered HCPCS Codes (When Selection Criteria Are Met)

Code	Type	Description Copy
J0172	HCPCS	Injection, aducanumab-avwa, 2 mg

Supporting CPT and HCPCS Codes Referenced in CPB 0996

These codes support the diagnostic workup, administration, and exclusion criteria. They are not independently covered under this CPB — coverage follows the procedures they describe.

Key ICD-10-CM Diagnosis Codes

---