Difelikefalin Injection (Korsuva) — CPB 1028 | AETNA Coverage Update

Aetna modified CPB 1028 covering difelikefalin (Korsuva) injection, effective January 5, 2026. Here's what billing teams need to know before submitting claims under J0879.

Aetna, a CVS Health company, updated its Korsuva coverage policy under CPB 1028 Aetna's Clinical Policy Bulletin system. The policy governs difelikefalin injection (J0879) for moderate-to-severe pruritus in adult hemodialysis patients. If your practice or dialysis facility bills HCPCS J0879 or administers IV push injections under CPT 96374–96379, this policy change sets the exact criteria you need to meet before you bill.

Quick-Reference Table

Aetna Difelikefalin Coverage Criteria and Medical Necessity Requirements 2026

The Aetna difelikefalin (Korsuva) coverage policy requires precertification before you administer or bill this drug. Call (866) 752-7021 or fax (888) 267-3277 to initiate precertification. This is not optional — all Aetna participating providers and members in applicable plan designs must get prior authorization before treatment starts.

Medical necessity approval for J0879 requires every one of seven criteria. Miss one, and you're looking at a claim denial. Here's the full list:

The prescriber must be a nephrologist or work in documented consultation with one. No other specialty can independently prescribe this drug under this coverage policy.

For continuation of therapy, the member must still meet all initial criteria. They also need documented clinical response — specifically, an improvement of at least four points from baseline on the WI-NRS. That threshold matters. If your clinical notes don't reflect a four-point improvement with an explicit baseline score, continuation authorization will fail.

The real issue with Korsuva billing is that the documentation requirements are clinical, not administrative. Your revenue cycle team cannot manufacture a WI-NRS score. That score needs to be in the chart before precertification goes in. Coordinate with your clinical team to embed this scoring into intake and ongoing assessment workflows — not as an afterthought when reauthorization comes up.

Aetna Difelikefalin Exclusions and Non-Covered Indications

Aetna will not cover difelikefalin injection for members on peritoneal dialysis. The policy states this directly: difelikefalin injection has not been studied in this population. There is no workaround. Even if a peritoneal dialysis patient has severe CKD-aP, J0879 is excluded under this coverage policy.

All other indications beyond moderate-to-severe CKD-aP in adult hemodialysis patients are considered experimental, investigational, or unproven. Aetna does not list specific off-label uses — they simply draw a hard line around the FDA-approved indication and leave everything else as non-covered.

If you're treating pruritus associated with other conditions — liver disease, malignancy, or dermatologic diagnoses — this drug will not get covered regardless of symptom severity.

Coverage Indications at a Glance

Aetna Difelikefalin Billing Guidelines and Action Items 2026

The effective date is January 5, 2026. If your team hasn't aligned workflows to this coverage policy already, do it now.

If your patient mix includes a high volume of dialysis patients with CKD-aP and your team hasn't mapped these workflows yet, loop in your compliance officer before submitting under the updated policy. The criteria are specific enough that a systematic documentation gap could produce widespread denials.

CPT, HCPCS, and ICD-10 Codes for Difelikefalin Injection Under CPB 1028

Covered HCPCS Codes (When Selection Criteria Are Met)

CPT Administration Codes Related to CPB 1028

Key ICD-10-CM Diagnosis Codes

A note on the L29 codes: Aetna's policy lists all ten subcategories of L29 without distinguishing between them. The policy does not specify which L29 subcode to use. Select the code that best matches the clinical documentation. Just don't submit Z99.2 without one of these — the pairing requirement is explicit.