Risankizumab-rzaa (Skyrizi) — CPB 1009 | AETNA Coverage Update

Aetna modified CPB 1009 covering risankizumab-rzaa (Skyrizi), effective September 26, 2025. Here's what billing teams need to know before claims go out.

Aetna, a CVS Health company, updated Clinical Policy Bulletin CPB 1009 for risankizumab-rzaa (Skyrizi) on September 26, 2025. This coverage policy governs intravenous Skyrizi across commercial medical plans and carries a hard precertification requirement. The policy covers a wide range of gastrointestinal procedures—including CPT codes 43233–43259 (esophagogastroduodenoscopy), 44360–44379 (small intestine endoscopy), 44380–44408 (stomal endoscopy), and 45300 and above for colorectal endoscopy—plus 36 HCPCS codes and 15 ICD-10-CM diagnosis codes. Miss the prior authorization step, and you're looking at a claim denial before the drug even ships.

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Quick-Reference Table

Field	Detail Copy
Payer	Aetna, a CVS Health company
Policy	Risankizumab-rzaa (Skyrizi) — CPB 1009
Policy Code	CPB 1009
Change Type	Modified
Effective Date	September 26, 2025
Impact Level	High
Specialties Affected	Gastroenterology, Rheumatology, Dermatology, Infusion/Specialty Pharmacy, Revenue Cycle
Key Action	Confirm precertification is obtained before infusion; call (866) 752-7021 or fax SMN forms to (888) 267-3277

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Aetna Risankizumab-rzaa Coverage Criteria and Medical Necessity Requirements 2025

The Aetna risankizumab-rzaa coverage policy under CPB 1009 applies to commercial medical plan members only. Medicare criteria live in a separate policy—check Aetna's Part B step therapy page for those members before you bill.

The core requirement is straightforward: precertification is mandatory for all intravenous risankizumab-rzaa claims. This applies to every Aetna participating provider and member in applicable plan designs. There is no exception pathway around it.

How to get precertification:

#	Covered Indication Copy
1	Phone: (866) 752-7021
2	Fax: (888) 267-3277
3	Forms: Statement of Medical Necessity (SMN) forms are available at Aetna's Specialty Pharmacy Precertification page

Medical necessity documentation needs to be in hand before the infusion date. If your practice submits claims without a precertification number, expect denial. Aetna won't retroactively approve intravenous Skyrizi just because the infusion already happened.

The prior authorization requirement here is firm. This isn't a soft edit or a courtesy review—it's a hard stop. Risankizumab-rzaa billing for the IV formulation requires the auth number attached to the claim. Build that into your workflow before September 26, 2025.

The policy scope is broader than most teams realize. CPB 1009 Aetna covers not just the drug administration itself but a large set of related diagnostic and endoscopic procedures. This makes sense clinically—Skyrizi's indications include Crohn's disease and ulcerative colitis, conditions monitored heavily with endoscopy. That's why 213 CPT codes appear in the policy, including the full range of esophagogastroduodenoscopy codes (43233–43259), small intestine endoscopy codes (44360–44379), stomal endoscopy codes (44380–44408), and colorectal endoscopy codes starting at 45300.

Your reimbursement on the associated procedural codes depends on the diagnosis codes submitted. Make sure your ICD-10-CM codes align with the 15 diagnosis codes Aetna lists under CPB 1009. A mismatch between the drug claim and the procedure claim is a common audit trigger.

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Coverage Indications at a Glance

The policy summary does not enumerate individual indication-level criteria with distinct coverage statuses in the data provided. What CPB 1009 does establish clearly is the precertification framework and the scope of related procedures. Here's what the policy structure tells you:

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Aetna Risankizumab-rzaa Billing Guidelines and Action Items 2025

The effective date is September 26, 2025. Here's what your team needs to do before that date—and what to check on claims submitted after it.

Copy Action Items

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CPT, HCPCS, and ICD-10 Codes for Risankizumab-rzaa (Skyrizi) Under CPB 1009

The full policy lists 213 CPT codes, 36 HCPCS codes, and 15 ICD-10-CM codes. The CPT codes below represent all codes included in the policy data provided. For the complete HCPCS and ICD-10 code lists, access the full policy at app.payerpolicy.org/p/aetna/1009.

CPT Codes Referenced in CPB 1009

These are listed as "Other CPT codes related to the CPB"—meaning they appear in the context of the policy but are associated procedures, not the primary drug administration codes.

Esophagogastroduodenoscopy (EGD) Codes

Small Intestine Endoscopy Codes

Stomal Endoscopy Codes

Colorectal Endoscopy Codes

The policy data provided includes 133 additional CPT codes in this and related categories. Access the complete list at app.payerpolicy.org/p/aetna/1009.

HCPCS and ICD-10-CM Codes

The policy references 36 HCPCS codes and 15 ICD-10-CM diagnosis codes. The specific codes were not included in the data extract provided here. Pull the full code lists directly from CPB 1009 at app.payerpolicy.org/p/aetna/1009. For Skyrizi billing, the HCPCS drug administration codes are the ones your team needs to prioritize—those drive the prior authorization trigger.

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A Note on This Policy's Scope

Here's the honest read on CPB 1009: the data provided gives us the precertification framework clearly, but the full medical necessity criteria—the detailed coverage criteria for each indication, the step therapy requirements, the continuation criteria—live in the full CPB document. The endoscopy CPT codes listed are supporting codes, not the primary billing codes for the drug itself.

The real financial exposure here is the drug cost. Risankizumab-rzaa IV is a high-cost biologic. A single denied claim denial for missing prior authorization isn't a nuisance—it's a significant write-off. Aetna's billing guidelines on this are not ambiguous. Precertify, or don't bill.

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