If you are a provider that accepts Aetna Medicare and commercial plan members? Then this blog post is for you!

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What is changing?

• New medical necessity criteria

Which Codes are affected?

• 99453-99458

The effective Date?

For any requests that are done on or after 3/1/26

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Updated Medical Criteria: qualifying conditions

• Hypertension
• Heart failure
• Diabetes

Documentation/clinical requirenment:

• Must be ordered by a qualifying provider
• Gathered information must be sent over to the plan in order to inform and adjust member treatment regiment
• Member needs to provider a written concent for RPM

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Accepted technology:

• FDA approved device
• Device has to be capable of transmitting  (automatically) physiological info

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What doesn’t meet the criteria?

• Other conditions besides the ones listed above
• The device is not FDA approved

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Additional information:

• For members that received 90 days of monitoring before 3/1/26- the member may continue receiving the cervice through 8/31/26
• Beginning DOS 9/1/26- this updated policy update will apply to all AETNA members (plans)

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Find this type of content useful? Follow my blog for more!

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