Aetna · Clinical coverage policy

Aetna Endoscopic Ultrasonography coverage criteria

Aetna CPB 0446 covers endoscopic ultrasonography (EUS), including with fine-needle aspiration and EUS-guided therapeutic procedures, as medically necessary only for a defined list of indications such as diagnosing/staging GI, pancreatic, biliary, and lung cancers, evaluating pancreatic/biliary/GI-wall abnormalities, idiopathic acute pancreatitis, gallbladder or biliary drainage, fiducial placement, tissue sampling, surveillance of certain small gastric sub-epithelial masses, and celiac plexus block/neurolysis. The key gate is that the indication must fall within this Section I list; EUS for any other use is deemed experimental/investigational, and staging is not covered when the tumor is already shown metastatic by other imaging (unless it drives a therapeutic decision) or when results will not alter the member's care.

Policy CPB 0446 · Effective · Verify against the current Aetna policy before submitting — view source policy.

Payer

Aetna

Policy

CPB 0446

Prior auth

Confirm

Effective

January 1, 2026

This page reflects the coverage criteria captured from Aetna policy CPB 0446 and may not include every criterion, exception, or code — verify the complete bulletin before submitting.

What this means for the claim

The covered path, the next step to get it approved, and the specific way it denies — built only from this policy.

When does Aetna cover Endoscopic Ultrasonography (CPT 43231), and what gets it denied?

Path
Aetna CPB 0446 covers endoscopic ultrasonography (EUS), including with fine-needle aspiration and EUS-guided therapeutic procedures, as medically necessary only for a defined list of indications such as diagnosing/staging GI, pancreatic, biliary, and lung cancers, evaluating pancreatic/biliary/GI-wall abnormalities, idiopathic acute pancreatitis, gallbladder or biliary drainage, fiducial placement, tissue sampling, surveillance of certain small gastric sub-epithelial masses, and celiac plexus block/neurolysis. The key gate is that the indication must fall within this Section I list; EUS for any other use is deemed experimental/investigational, and staging is not covered when the tumor is already shown metastatic by other imaging (unless it drives a therapeutic decision) or when results will not alter the member's care. Coverage criteria include: Aetna considers endoscopic ultrasonography (EUS) medically necessary for ANY of the following indications (Section I); Diagnosing common bile duct stones; Evaluating abnormalities of the biliary tree; Evaluating abnormalities of the gastrointestinal tract wall or adjacent structures; Evaluating abnormalities of the pancreas, including masses, pseudocysts, and chronic pancreatitis; Evaluating adenopathy and masses of the posterior mediastinum (EUS with fine-needle aspiration); Evaluating idiopathic acute pancreatitis; Gallbladder drainage for acute cholecystitis; Placement of fiducials into tumors within or adjacent to the wall of the gastrointestinal tract; Providing endoscopic therapy under ultrasonographic guidance; Providing EUS-guided biliary drainage for palliation of malignant biliary obstruction; Sampling tissue of lesions within, or adjacent to, the wall of the gastrointestinal tract; Staging of lung cancer (EUS with fine-needle aspiration); Staging tumors of the gastrointestinal tract (esophagus, stomach, rectum), pancreas, and bile ducts; Surveillance of certain gastric sub-epithelial masses (asymptomatic glomus tumors or small <3 cm gastrointestinal stromal tumors); Celiac plexus block for chronic pancreatitis, or celiac plexus neurolysis for pancreatic cancer. Applies to 13 codes: 43231, 43232, 43237, 43238, 43240, 43242, 43253, 43259, 45341, 45342, 45391, 45392, 76975.
Action
Confirm prior-authorization status with Aetna before scheduling — it is code- and plan-specific, and this policy is not an exact authorization source.
Trap
Policy exclusions and limitations: Aetna considers EUS experimental, investigational, or unproven for all other indications not listed in Section I, including the following conditions (because the effectiveness for these indications has not been established); Diagnosis of esophageal varices; EUS-elastography (for differentiation of benign and malignant pancreatic masses; differential diagnosis of malignant lymph nodes; for adrenal glands, hepatobiliary/gastrointestinal tract pathology (including anal canal), lung, mediastinum, and urogenital tract); Evaluation of common bile duct dilation in persons without signs or symptoms; Staging of tumors shown to be metastatic by other imaging methods (UNLESS the results are the basis for therapeutic decisions); When the results will not alter care of the member; Endoscopic ultrasonography-guided ablation therapies for the treatment of pancreatic cystic neoplasms; Endoscopic ultrasonography-guided ethanol injection for the treatment of pancreatic neuroendocrine neoplasms; Endoscopic ultrasonography-guided interstitial brachytherapy for the treatment of un-resectable pancreatic cancer; Endoscopic ultrasonography-guided radiofrequency ablation for the treatment of pancreatic neuroendocrine neoplasms; EchoTip Insight (an endoscopic ultrasound-guided device) for direct measurement of hepatic portosystemic pressure gradient. Claims may be denied when the requested service falls under these. Some of these are conditional (note the stated exceptions) — confirm specifics against the bulletin.

Source: Aetna CPB 0446 — Endoscopic Ultrasonography

Coverage criteria

  • Aetna considers endoscopic ultrasonography (EUS) medically necessary for ANY of the following indications (Section I)
  • Diagnosing common bile duct stones
  • Evaluating abnormalities of the biliary tree
  • Evaluating abnormalities of the gastrointestinal tract wall or adjacent structures
  • Evaluating abnormalities of the pancreas, including masses, pseudocysts, and chronic pancreatitis
  • Evaluating adenopathy and masses of the posterior mediastinum (EUS with fine-needle aspiration)
  • Evaluating idiopathic acute pancreatitis
  • Gallbladder drainage for acute cholecystitis
  • Placement of fiducials into tumors within or adjacent to the wall of the gastrointestinal tract
  • Providing endoscopic therapy under ultrasonographic guidance
  • Providing EUS-guided biliary drainage for palliation of malignant biliary obstruction
  • Sampling tissue of lesions within, or adjacent to, the wall of the gastrointestinal tract
  • Staging of lung cancer (EUS with fine-needle aspiration)
  • Staging tumors of the gastrointestinal tract (esophagus, stomach, rectum), pancreas, and bile ducts
  • Surveillance of certain gastric sub-epithelial masses (asymptomatic glomus tumors or small <3 cm gastrointestinal stromal tumors)
  • Celiac plexus block for chronic pancreatitis, or celiac plexus neurolysis for pancreatic cancer

Covered codes

Codes listed in this Aetna policy. Check each one's prior-authorization verdict and Medicare rate:

Frequently asked questions

When does Aetna cover Endoscopic Ultrasonography (CPT 43231), and what gets it denied?
Aetna CPB 0446 covers endoscopic ultrasonography (EUS), including with fine-needle aspiration and EUS-guided therapeutic procedures, as medically necessary only for a defined list of indications such as diagnosing/staging GI, pancreatic, biliary, and lung cancers, evaluating pancreatic/biliary/GI-wall abnormalities, idiopathic acute pancreatitis, gallbladder or biliary drainage, fiducial placement, tissue sampling, surveillance of certain small gastric sub-epithelial masses, and celiac plexus block/neurolysis. The key gate is that the indication must fall within this Section I list; EUS for any other use is deemed experimental/investigational, and staging is not covered when the tumor is already shown metastatic by other imaging (unless it drives a therapeutic decision) or when results will not alter the member's care. Coverage criteria include: Aetna considers endoscopic ultrasonography (EUS) medically necessary for ANY of the following indications (Section I); Diagnosing common bile duct stones; Evaluating abnormalities of the biliary tree; Evaluating abnormalities of the gastrointestinal tract wall or adjacent structures; Evaluating abnormalities of the pancreas, including masses, pseudocysts, and chronic pancreatitis; Evaluating adenopathy and masses of the posterior mediastinum (EUS with fine-needle aspiration); Evaluating idiopathic acute pancreatitis; Gallbladder drainage for acute cholecystitis; Placement of fiducials into tumors within or adjacent to the wall of the gastrointestinal tract; Providing endoscopic therapy under ultrasonographic guidance; Providing EUS-guided biliary drainage for palliation of malignant biliary obstruction; Sampling tissue of lesions within, or adjacent to, the wall of the gastrointestinal tract; Staging of lung cancer (EUS with fine-needle aspiration); Staging tumors of the gastrointestinal tract (esophagus, stomach, rectum), pancreas, and bile ducts; Surveillance of certain gastric sub-epithelial masses (asymptomatic glomus tumors or small <3 cm gastrointestinal stromal tumors); Celiac plexus block for chronic pancreatitis, or celiac plexus neurolysis for pancreatic cancer. Applies to 13 codes: 43231, 43232, 43237, 43238, 43240, 43242, 43253, 43259, 45341, 45342, 45391, 45392, 76975. Confirm prior-authorization status with Aetna before scheduling — it is code- and plan-specific, and this policy is not an exact authorization source. Policy exclusions and limitations: Aetna considers EUS experimental, investigational, or unproven for all other indications not listed in Section I, including the following conditions (because the effectiveness for these indications has not been established); Diagnosis of esophageal varices; EUS-elastography (for differentiation of benign and malignant pancreatic masses; differential diagnosis of malignant lymph nodes; for adrenal glands, hepatobiliary/gastrointestinal tract pathology (including anal canal), lung, mediastinum, and urogenital tract); Evaluation of common bile duct dilation in persons without signs or symptoms; Staging of tumors shown to be metastatic by other imaging methods (UNLESS the results are the basis for therapeutic decisions); When the results will not alter care of the member; Endoscopic ultrasonography-guided ablation therapies for the treatment of pancreatic cystic neoplasms; Endoscopic ultrasonography-guided ethanol injection for the treatment of pancreatic neuroendocrine neoplasms; Endoscopic ultrasonography-guided interstitial brachytherapy for the treatment of un-resectable pancreatic cancer; Endoscopic ultrasonography-guided radiofrequency ablation for the treatment of pancreatic neuroendocrine neoplasms; EchoTip Insight (an endoscopic ultrasound-guided device) for direct measurement of hepatic portosystemic pressure gradient. Claims may be denied when the requested service falls under these. Some of these are conditional (note the stated exceptions) — confirm specifics against the bulletin.
Does Aetna require prior authorization for Endoscopic Ultrasonography?
Confirm prior-authorization status with Aetna before scheduling — it is code- and plan-specific, and this policy is not an exact authorization source.
What does Aetna exclude for Endoscopic Ultrasonography?
Policy exclusions and limitations: Aetna considers EUS experimental, investigational, or unproven for all other indications not listed in Section I, including the following conditions (because the effectiveness for these indications has not been established); Diagnosis of esophageal varices; EUS-elastography (for differentiation of benign and malignant pancreatic masses; differential diagnosis of malignant lymph nodes; for adrenal glands, hepatobiliary/gastrointestinal tract pathology (including anal canal), lung, mediastinum, and urogenital tract); Evaluation of common bile duct dilation in persons without signs or symptoms; Staging of tumors shown to be metastatic by other imaging methods (UNLESS the results are the basis for therapeutic decisions); When the results will not alter care of the member; Endoscopic ultrasonography-guided ablation therapies for the treatment of pancreatic cystic neoplasms; Endoscopic ultrasonography-guided ethanol injection for the treatment of pancreatic neuroendocrine neoplasms; Endoscopic ultrasonography-guided interstitial brachytherapy for the treatment of un-resectable pancreatic cancer; Endoscopic ultrasonography-guided radiofrequency ablation for the treatment of pancreatic neuroendocrine neoplasms; EchoTip Insight (an endoscopic ultrasound-guided device) for direct measurement of hepatic portosystemic pressure gradient. Claims may be denied when the requested service falls under these. Some of these are conditional (note the stated exceptions) — confirm specifics against the bulletin.

Source

Aetna CPB 0446 — Endoscopic Ultrasonography

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Coverage disclaimer

This page summarizes Aetna clinical-coverage criteria extracted from policy CPB 0446 for educational purposes. Coverage policies change and vary by individual plan. Always verify against Aetna's current policy before performing a procedure or submitting a claim. d3rx is not responsible for claim denials or reimbursement issues.