Pozelimab-bbfg (Veopoz) — CPB 1043 | AETNA Coverage Update

Aetna modified CPB 1043 for pozelimab-bbfg (Veopoz), effective December 10, 2025. Here's what billing teams need to know before submitting claims.

Aetna, a CVS Health company, updated its Veopoz coverage policy under CPB 1043 Aetna system. This change defines the exact medical necessity criteria for pozelimab-bbfg — a complement inhibitor used exclusively for CD55-deficient protein-losing enteropathy (CHAPLE disease). If your practice or infusion center bills CPT 96365 or 96369 for this drug, this policy governs whether Aetna pays. Get the criteria wrong, and you're looking at a claim denial before the first infusion is even scheduled.

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Quick-Reference Table

Field	Detail Copy
Payer	Aetna
Policy	Pozelimab-bbfg (Veopoz) — CPB 1043
Policy Code	CPB 1043
Change Type	Modified
Effective Date	December 10, 2025
Impact Level	High — prior authorization required; strict genotypic and lab criteria apply
Specialties Affected	Gastroenterology, Hematology, Immunology, Infusion/Specialty Pharmacy
Key Action	Confirm biallelic CD55 genotype and serum albumin ≤3.2 g/dL before submitting precertification

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Aetna Pozelimab-bbfg Coverage Criteria and Medical Necessity Requirements 2025

The Aetna Veopoz coverage policy is narrow by design. Pozelimab-bbfg has exactly one approved indication under CPB 1043: CD55-deficient protein-losing enteropathy, also called CHAPLE disease. There is no flexibility here. If the member doesn't meet all three tiers of criteria below, Aetna will not authorize it.

Tier 1: Genotypic Confirmation

The member must have a confirmed biallelic CD55 loss-of-function mutation. This means genotype analysis showing both alleles are affected — not just clinical suspicion or a family history of complement deficiency. Your prior authorization submission needs documentation of the actual genetic test result. No genotype report, no authorization.

Tier 2: Lab-Confirmed Hypoalbuminemia

Serum albumin must be at or below 3.2 g/dL at time of request. Bill CPT 82040 (albumin; serum, plasma or whole blood) to document this. The lab value needs to be current — don't submit a result from a year ago and expect it to hold up under clinical review.

Tier 3: Active Signs and Symptoms (Within the Past Six Months)

The member must show at least one of four specific symptoms within the past six months:

All three tiers are required simultaneously. One missing element — even if the other two are solid — is enough to trigger a denial. This is an AND-AND structure in the medical necessity criteria, not OR.

Prior Authorization Process

Precertification is mandatory for all Aetna participating providers and members in applicable plan designs. To submit, call (866) 752-7021 or fax (888) 267-3277. For Statement of Medical Necessity (SMN) forms, go to Aetna's Specialty Pharmacy Precertification page.

The Site of Care Utilization Management Policy also applies. Aetna's site-of-service rules for specialty drug infusions govern where this drug can be administered — not just whether it's covered. Check Aetna's drug infusion site-of-care policy before assuming the patient can receive treatment in a hospital outpatient setting versus an office or home infusion environment. A mismatch here affects reimbursement even when the clinical criteria are met.

Continuation of Therapy

Reauthorization requires documented positive response to therapy. Aetna accepts: normalization of serum albumin, improvement in signs and symptoms, or a decrease in hospitalizations and infections. Document all three where possible — more evidence is better at renewal time.

The absence of unacceptable toxicity is also required. If the member has had a significant adverse event, document how it was managed and why continued therapy is appropriate. Don't let a toxicity note sit unaddressed in the chart without clinical context.

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Aetna Veopoz Exclusions and Non-Covered Indications

This section is short because Aetna's position is absolute. Any use of pozelimab-bbfg outside of CD55-deficient PLE is considered experimental, investigational, or unproven. Full stop.

There are no other approved indications under CPB 1043. If a prescriber is using Veopoz off-label — for another complement-mediated condition, for example — Aetna will not cover it under this coverage policy. Don't submit it. You will get a denial and burn through appeal resources on a case that has no policy support.

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Coverage Indications at a Glance

Indication	Status	Relevant Codes	Notes Copy
CD55-deficient protein-losing enteropathy (CHAPLE disease) — initial therapy	Covered	ICD-10 D84.1; CPT 96365 or 96369; CPT 82040	All three criteria tiers must be met; prior auth required via (866) 752-7021
CD55-deficient PLE — continuation of therapy	Covered	ICD-10 D84.1; CPT 96365 or 96369	Requires documented positive response; no unacceptable toxicity
All other indications for pozelimab-bbfg	Not Covered — Experimental/Investigational	N/A	No exceptions under CPB 1043

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Aetna Veopoz Billing Guidelines and Action Items 2025

The effective date of December 10, 2025 means this policy is active now. These steps apply immediately.

Copy Action Items

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CPT, HCPCS, and ICD-10 Codes for Pozelimab-bbfg Under CPB 1043

Covered CPT Codes (When Selection Criteria Are Met)

Code	Type	Description Copy
96365	CPT	Intravenous infusion, for therapy, prophylaxis, or diagnosis; initial, up to 1 hour
96369	CPT	Subcutaneous infusion for therapy or prophylaxis; initial, up to 1 hour

Supporting/Diagnostic CPT Codes

Code	Type	Description Copy
82040	CPT	Albumin; serum, plasma or whole blood

CPT 82040 is the lab code that documents hypoalbuminemia — one of the three required criteria for initial approval. Bill it when drawing the serum albumin that supports the medical necessity determination. It's not the treatment code, but it's part of the evidence trail that keeps your authorization intact.

Key ICD-10-CM Diagnosis Codes

Code	Description Copy
D84.1	Defects in the complement system [CD55-deficient protein-losing enteropathy (PLE)]

D84.1 is the only ICD-10 code connected to CPB 1043. It's your covered diagnosis. Every claim for pozelimab-bbfg Veopoz billing should carry this code on the primary diagnosis line.

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