Aetna modified CPB 1003 for tezepelumab-ekko (Tezspire), effective February 7, 2026. Here's what billing teams need to know.
Aetna, a CVS Health company, updated Clinical Policy Bulletin 1003 to expand covered indications for tezepelumab-ekko (Tezspire) beyond severe asthma to include chronic rhinosinusitis with nasal polyps (CRSwNP). This CPB 1003 Aetna coverage policy change affects precertification workflows, prescriber eligibility, and step-therapy requirements for commercial plans. If your practice bills for specialty biologics across pulmonology, allergy/immunology, or otolaryngology, this update changes who qualifies and what documentation you need before submitting a claim.
Quick-Reference Table
| Field | Detail |
|---|---|
| Payer | Aetna, a CVS Health company |
| Policy | Tezepelumab-ekko (Tezspire) — CPB 1003 |
| Policy Code | CPB 1003 |
| Change Type | Modified |
| Effective Date | February 7, 2026 |
| Impact Level | High |
| Specialties Affected | Allergy/Immunology, Pulmonology, Otolaryngology |
| Key Action | Update precertification workflows for both asthma and new CRSwNP indications before processing any Tezspire claims under commercial plans |
Aetna Tezepelumab-ekko Coverage Criteria and Medical Necessity Requirements 2026
The real issue with this updated coverage policy is the two-track structure. Aetna will approve Tezspire under medical necessity for the same patient two different ways — and which track you use determines what documentation your team needs to collect before submitting for prior authorization.
Track 1: Prior Biologic Use (Faster Path)
This is the shortcut track. For both asthma and CRSwNP, Aetna considers tezepelumab-ekko medically necessary if the member is 12 or older and has received a biologic indicated for that condition in the past year.
For asthma, prior biologic use means drugs like Dupixent (dupilumab) or Nucala (mepolizumab). For CRSwNP, prior biologics include Nucala, Xolair (omalizumab), or Dupixent. No exacerbation history required. No imaging required. Document the prior biologic and dates of use, and you're set.
Track 2: Severe Disease Criteria (More Documentation)
If the member hasn't used a prior biologic, Aetna requires all of the following for asthma approval:
| # | Covered Indication |
|---|---|
| 1 | Member is 12 years of age or older |
| 2 | Uncontrolled asthma, proven by at least one of: two or more exacerbations requiring oral or injectable corticosteroids in the past year, one or more exacerbations resulting in hospitalization or emergency care, or poor symptom control (frequent symptoms, activity limitation, or night waking) |
| 3 | Inadequate control despite both a high-dose inhaled corticosteroid AND an additional controller (long-acting beta₂-agonist, long-acting muscarinic antagonist, leukotriene modifier, or sustained-release theophylline) at optimized doses |
| 4 | Member will continue maintenance therapy (inhaled corticosteroid plus controller) alongside Tezspire |
For CRSwNP approval without prior biologic use, the criteria are:
| # | Covered Indication |
|---|---|
| 1 | Member is 12 or older |
| 2 | Bilateral nasal polyposis with chronic sinusitis symptoms despite intranasal corticosteroid use for at least four weeks (unless contraindicated or not tolerated) |
| 3 | CRSwNP persisting despite prior sino-nasal surgery OR prior systemic corticosteroids within the last two years that were ineffective (unless contraindicated or not tolerated) |
| 4 | Documented polyp severity via one of: bilateral nasal endoscopy (CPT 31231), anterior rhinoscopy, or CT of the maxillofacial area (CPT 70486–70488) showing polyps reaching below the lower border of the middle turbinate in each nostril; OR a Meltzer Clinical Score of two or higher in both nostrils |
That imaging documentation requirement for CRSwNP is where claim denials will happen. If a CT wasn't ordered or an endoscopy wasn't coded correctly, you don't have what Aetna needs.
Prescriber Requirements
This is non-negotiable under the updated policy. Tezspire must be prescribed by — or in documented consultation with — a specialist.
| # | Covered Indication |
|---|---|
| 1 | Asthma: allergist/immunologist or pulmonologist |
| 2 | CRSwNP: allergist/immunologist or otolaryngologist |
A primary care physician prescribing Tezspire without documented specialist consultation will trigger a denial. Confirm the prescriber of record before submitting the prior authorization request.
Precertification and Site of Care
Precertification is required for all participating providers and members in applicable plan designs. Call (866) 752-7021 or fax (888) 267-3277. Use the Specialty Pharmacy Precertification SMN forms from Aetna's provider portal.
Aetna's Site of Care Utilization Management Policy also applies. Reimbursement for Tezspire administration isn't automatic at any setting — Aetna will evaluate the site of service. Review the Site of Care for Specialty Drug Infusions policy before scheduling infusions.
Aetna Tezepelumab-ekko Exclusions and Non-Covered Indications
The policy doesn't cover Tezspire for members under 12 years of age for either indication. There is no approved indication for pediatric patients below that threshold under this commercial coverage policy.
Asthma patients who haven't tried a prior biologic AND don't meet all four of the severe asthma criteria listed above don't qualify. One missing element — say, a member on medium-dose rather than high-dose inhaled corticosteroids — is enough for Aetna to deny medical necessity.
For CRSwNP, members who haven't had prior surgery or systemic corticosteroid treatment (and for whom those aren't contraindicated) won't qualify on the non-biologic track. The step-therapy requirement here is strict.
Coverage Indications at a Glance
| Indication | Status | Notes |
|---|---|---|
| Severe asthma — prior biologic use in past year (age ≥12) | Covered | Prescriber must be allergist/immunologist or pulmonologist; prior auth required |
| Severe asthma — meets all 4 disease criteria (age ≥12) | Covered | High-dose ICS + controller required; member must continue maintenance therapy |
| CRSwNP — prior biologic use in past year (age ≥12) | Covered | Prescriber must be allergist/immunologist or otolaryngologist; prior auth required |
| CRSwNP — meets all disease criteria (age ≥12) | Covered | Requires imaging or Meltzer score ≥2 in both nostrils; prior surgery or systemic steroid failure required |
| Asthma or CRSwNP — age under 12 | Not Covered | No approved indication for members under 12 |
| Asthma without prior biologic, not meeting all severe criteria | Not Covered | All four criteria must be met simultaneously |
| CRSwNP without prior surgery or systemic steroid failure (not contraindicated) | Not Covered | Step-therapy required unless contraindicated |
Related CPT, HCPCS, and ICD-10-CM codes are listed in the full CPB 1003 policy document but are not mapped to specific indications in the available policy data extract. See the code tables below and confirm usage against the full policy at Aetna's provider portal.
Aetna Tezspire Billing Guidelines and Action Items 2026
The expansion to CRSwNP is the biggest operational change here. Your billing and prior authorization workflows were likely built around asthma only. That changes as of the February 7, 2026 effective date.
| # | Action Item |
|---|---|
| 1 | Update your precertification intake forms to capture the new CRSwNP indication fields: bilateral polyposis documentation, intranasal corticosteroid history, prior surgery or systemic steroid history, and imaging or Meltzer score results. Do this now if you haven't already — the effective date has passed. |
| 2 | Audit your prescriber credentialing records for any Tezspire prescriptions. Otolaryngologists are now valid prescribers for CRSwNP cases, but they aren't valid for asthma. A cross-indication prescribing error will cause a denial. Confirm the prescriber's specialty matches the indication before each prior auth submission. |
| 3 | Code imaging accurately when supporting CRSwNP claims. The policy lists CPT 31231, 70486, 70487, and 70488 as related diagnostic procedure codes. Ensure that any imaging or endoscopy performed to document polyp severity is accurately coded and the clinical notes connect the procedure to the prior authorization documentation. Don't assume the claim reader will figure it out. |
| 4 | Build the prior biologic use shortcut into your workflow. If a member has Dupixent, Nucala, or Xolair history for either indication within the past year, that's a faster path to approval. Train your authorization staff to check biologic history first before pulling together the full disease-severity documentation package. |
| 5 | Confirm site of care before scheduling any infusion. Aetna's Site of Care policy applies to Tezspire. If a member's plan routes specialty drug infusions to a lower-cost setting and you're billing for hospital outpatient administration, you may face a reimbursement reduction or denial. Check the policy before the appointment, not after the claim drops. |
| 6 | Review continuation criteria for renewals. Tezspire billing for asthma requires that members continue maintenance therapy (inhaled corticosteroid plus controller) alongside the biologic. If a member has stopped their controller between the initial approval and the renewal, document why. Aetna will ask. |
If you're managing a mixed payer book and aren't sure how this CRSwNP expansion interacts with your current authorization workflows, talk to your billing consultant before your next Tezspire submission.
| 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 Tezepelumab-ekko Under CPB 1003
The policy data lists codes in three functional groups. These are the codes tied to diagnostic workup, related procedures, and step-therapy documentation — not the drug administration code itself (which is administered separately and subject to site-of-care policy).
Sino-Nasal Surgery and Diagnostic Procedure Codes
| Code | Type | Description |
|---|---|---|
| 30000–31299 | CPT Range | Nose and accessory sinuses — sino-nasal surgery |
| 31231 | CPT | Nasal endoscopy, diagnostic, unilateral or bilateral (separate procedure) |
| 31233 | CPT | Nasal endoscopy with maxillary sinusoscopy (via inferior meatus or canine fossa puncture) |
| 31235 | CPT | Nasal endoscopy with sphenoid sinusoscopy (via puncture of sphenoidal face or cannulation of ostium) |
| 70486 | CPT | Computed tomography, maxillofacial area |
| 70487 | CPT | Computed tomography, maxillofacial area |
| 70488 | CPT | Computed tomography, maxillofacial area |
Get the Full Picture for CPT 31231
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