Nedosiran (Rivfloza) — CPB 1047 | AETNA Coverage Update

TL;DR: Aetna modified CPB 1047 for nedosiran (Rivfloza) on February 21, 2026. Here's what billing teams need to act on now.

Aetna updated its nedosiran (Rivfloza) coverage policy under CPB 1047, with an effective date of February 21, 2026. This policy governs a rare disease injectable — nedosiran — used for primary hyperoxaluria type 1 (PH1). The primary administration code is CPT 96372, and oxalate testing under CPT 83945 is the key lab code tied to medical necessity documentation. If your practice bills for specialty nephrology, genetics, or urology services, this policy is on your radar now.

Quick-Reference Table

Aetna Nedosiran Coverage Criteria and Medical Necessity Requirements 2026

The Aetna nedosiran coverage policy under CPB 1047 sets a tight, six-part checklist for initial approval. Every criterion must be met. Miss one, and you're looking at a claim denial.

Age: The member must be 2 years of age or older.

Diagnosis confirmation: PH1 must be confirmed by one of two routes — either molecular genetic testing showing a pathogenic variant in the AGXT gene, or liver enzyme analysis showing absent or significantly reduced alanine:glyoxylate aminotransferase (AGT) activity. CPT 84460 (alanine amino transferase) supports the enzyme analysis pathway. CPT 0259U is listed in the policy code set, but the source policy does not specify its role in the diagnostic pathway. Confirm applicability with your laboratory and compliance team before attaching it to an authorization request.

Elevated oxalate levels: The member must show elevated urinary oxalate, urinary oxalate:creatinine ratio, or plasma oxalate before starting therapy. CPT 83945 (oxalate) is the primary lab code here. CPT 82570 (creatinine, other source) supports the urinary oxalate:creatinine ratio. Both should be in the chart before you submit prior authorization.

Kidney function: The member must have relatively preserved kidney function — for example, an eGFR of 30 mL/min/1.73 m² or higher. CPT 80069 (renal function panel), CPT 82540 (creatine), CPT 82565 (creatinine, blood), CPT 82575 (creatinine clearance), CPT 0602T, and CPT 0603T (transdermal GFR measurement and monitoring) all support this documentation requirement. Transdermal GFR codes — 0602T and 0603T — are newer Category III codes; confirm your MAC or payer accepts them before attaching them to an authorization request.

No prior liver transplant: Members with liver transplant status (ICD-10 Z94.4) do not qualify. This is a hard exclusion.

No concurrent lumasiran: Nedosiran cannot be billed alongside lumasiran (Oxlumo). HCPCS J0224 is the lumasiran injection code. If J0224 appears anywhere in the member's recent claims history, flag it before submitting the nedosiran auth. The two drugs are mutually exclusive under this coverage policy — using both at once will trigger denial.

Precertification is mandatory. Call (866) 752-7021 or fax (888) 267-3277. Statement of Medical Necessity forms are available through Aetna's specialty pharmacy precertification portal. Rivfloza also carries Aetna's GCIT (Gene-based, Cellular & Other Innovative Therapies) designation, which means the Aetna GCIT team provides dedicated review of these requests. Confirm your authorization request is routed accordingly and build extra lead time into your workflow — GCIT-designated reviews may take longer than standard specialty drug authorizations. Contact Aetna's GCIT team directly to confirm current review timelines.

Site-of-care utilization management also applies. Where the drug is infused or injected matters for reimbursement. Review Aetna's Site of Care for Specialty Drug Infusions policy before scheduling administration. If you're billing CPT 96372 (subcutaneous or intramuscular injection) in a setting Aetna deems non-preferred, you risk a site-of-care denial on top of the medical necessity review.

Aetna Nedosiran Exclusions and Non-Covered Indications

Aetna's position here is clear: any indication outside PH1 is experimental, investigational, or unproven.

Nedosiran billing for any other form of hyperoxaluria — or any off-label use — will not get approved. ICD-10 E72.538 (other specified primary hyperoxaluria) is listed in the policy, but the covered diagnosis is specifically E72.530 (primary hyperoxaluria, type 1). Using E72.538 as your primary diagnosis on an authorization request is a red flag. Check with your physician on whether the member's confirmed diagnosis is specifically PH1 before you code it.

The real issue here is documentation discipline. PH1 is rare — some members may have a clinical diagnosis without formal genetic testing or enzyme analysis on file. Without one of those two confirmatory results, Aetna has grounds to deny on medical necessity even when the treating physician is confident in the diagnosis.

Coverage Indications at a Glance

Aetna Nedosiran Billing Guidelines and Action Items 2026

The effective date is February 21, 2026. If you're billing nedosiran (Rivfloza) for Aetna commercial members, these steps apply now.

If your billing team is new to GCIT-designated drugs or you have a mixed payer population where this policy intersects with Medicare, talk to your compliance officer before the effective date. The commercial and Medicare criteria differ, and Aetna handles them separately.

CPT, HCPCS, and ICD-10 Codes for Nedosiran (Rivfloza) Under CPB 1047

Covered CPT Codes (When Selection Criteria Are Met)

Key ICD-10-CM Diagnosis Codes