Aetna Multiple Sclerosis coverage criteria

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.

Coverage criteria

• Alemtuzumab (Lemtrada) must be prescribed by or in consultation with a neurologist.
• Alemtuzumab (Lemtrada) FIRST COURSE: medically necessary for members with a diagnosis of a relapsing form of MS (including relapsing-remitting and secondary progressive disease for those who continue to experience relapse) who have had an inadequate response to two or more drugs indicated for MS.
• Alemtuzumab (Lemtrada) SUBSEQUENT COURSES: medically necessary for members with a diagnosis of a relapsing form of MS (including relapsing-remitting and secondary progressive disease for those who continue to experience relapse) who have completed at least one previous course of therapy AND treatment will start at least 12 months after the last dose of the prior treatment course.
• Alemtuzumab (Lemtrada): members will NOT use Lemtrada concomitantly with other disease-modifying MS agents (Note: Ampyra and Nuedexta are not disease-modifying). Authorization may be granted for pediatric members under 18 years when benefits outweigh risks.
• Cladribine, dimethyl fumarate, diroximel fumarate, fingolimod, ozanimod, siponimod, teriflunomide, glatiramer acetate, and ofatumumab: refer to Aetna's Pharmacy Clinical Policy Bulletins (covered under pharmacy benefits).
• Interferon beta-1a (Rebif), interferon beta-1b (Betaseron/Extavia), and peginterferon beta-1a (Plegridy): refer to the specific pharmacy clinical policy bulletins.
• Intravenous (IV) steroid treatment is medically necessary for ONE of the following: (a) treatment of acute exacerbations of MS when the acute relapse is characterized by functionally disabling symptoms with documented evidence of neurological impairment; OR (b) use of intermittent pulse dose corticosteroids as a maintenance treatment for MS to delay disease progression.
• Hospital admission for IV steroid therapy is medically necessary when an acute exacerbation of MS results in ANY of the following severe neurological deficits: acute cerebral symptoms with severe loss of intellectual capacity; acute epileptic seizure(s); acute fulminant MS characterized by headache, vomiting, convulsions and eventually coma, with severe compromise of functioning of the central nervous system; acute pseudobulbar palsy; acute quadriplegia; acute transverse myelitis (or Brown-Sequard syndrome) with loss of function below the level of a suspected lesion in the spinal cord; acute visual loss; OR previous complications from high-dose IV steroids justifying inpatient admission.
• Mitoxantrone IV injection must be prescribed by or in consultation with a neurologist.
• Mitoxantrone IV injection INITIAL: medically necessary for members diagnosed with a relapsing form of MS (including relapsing-remitting, secondary progressive, and progressive relapsing disease). Note: mitoxantrone is NOT indicated in the treatment of primary progressive MS.
• Mitoxantrone IV injection CONTINUATION: medically necessary for members who meet initial criteria AND are experiencing disease stability or improvement, AND there is no evidence of unacceptable toxicity while receiving mitoxantrone therapy.
• Natalizumab: see CPB 0751 - Natalizumab (separate policy).
• Ocrelizumab (Ocrevus) or ocrelizumab and hyaluronidase-ocsq (Ocrevus Zunovo) must be prescribed by or in consultation with a neurologist.
• Ocrelizumab (Ocrevus / Ocrevus Zunovo) INITIAL: medically necessary for ONE of the following: (a) relapsing forms of MS (including relapsing-remitting and secondary progressive disease for those who continue to experience relapse); (b) clinically isolated syndrome (CIS) of MS; OR (c) primary progressive MS (PPMS).
• Ocrelizumab (Ocrevus / Ocrevus Zunovo) CONTINUATION: medically necessary for all members (including new members) with relapsing forms of MS, CIS, or PPMS who achieve or maintain a positive clinical response as evidenced by experiencing disease stability or improvement while receiving the requested medication.
• Ocrelizumab (Ocrevus / Ocrevus Zunovo): members will NOT use concomitantly with other disease-modifying MS agents (Note: Ampyra and Nuedexta excepted/not disease-modifying). Authorization may be granted for pediatric members under 18 years when benefits outweigh risks.
• Plasma exchange / plasmapheresis is medically necessary for members with acute, severe neurological deficits caused by MS who have a poor response to treatment with high-dose glucocorticoids.
• Rituximab: see CPB 0314 - Rituximab (separate policy).
• Ublituximab-xiiy (Briumvi) must be prescribed by or in consultation with a neurologist.
• Ublituximab-xiiy (Briumvi) INITIAL: medically necessary for ONE of the following: (a) relapsing forms of MS (including relapsing-remitting and secondary progressive disease for those who continue to experience relapse); OR (b) clinically isolated syndrome (CIS) of MS.
• Ublituximab-xiiy (Briumvi) CONTINUATION: medically necessary for all members (including new members) with relapsing forms of MS or CIS who achieve or maintain a positive clinical response as evidenced by experiencing disease stability or improvement while receiving the requested medication.
• Ublituximab-xiiy (Briumvi): members will NOT use Briumvi concomitantly with other disease-modifying MS agents (Note: Ampyra and Nuedexta excepted/not disease-modifying). Authorization may be granted for pediatric members under 18 years when benefits outweigh risks.
• DEFINITION - Failure of an adequate trial of therapy for MS is defined as ANY of the following: (1) the member has increasing relapses (defined as two or more relapses in a year, OR one severe relapse associated with either poor recovery or MRI lesion progression); (2) the member has lesion progression by MRI (increased number or volume of gadolinium-enhancing lesions, T2 hyperintense lesions, or T1 hypointense lesions); OR (3) the member has worsening disability (sustained worsening of Expanded Disability Status Scale (EDSS) score or neurological examination findings).
• DEFINITION - Intolerance is defined as intolerable side effects despite optimized management strategies.

Covered codes

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

• 36514·PA verdict·Rate
• J0202·PA verdict·Rate
• J2323·PA verdict·Rate
• J2329·PA verdict·Rate
• J2350·PA verdict·Rate
• J2351·PA verdict·Rate
• J9293·PA verdict·Rate

Documentation required

• Documented evidence of neurological impairment for acute exacerbations treated with IV steroids.
• Evidence of prior medication trials / inadequate response to two or more drugs indicated for MS (for alemtuzumab/Lemtrada).
• MRI evidence of lesion progression (gadolinium-enhancing lesions, T2 hyperintense lesions, or T1 hypointense lesions) where used to establish treatment failure.
• Expanded Disability Status Scale (EDSS) score or neurological examination findings to document worsening disability where used to establish treatment failure.
• Evidence of positive clinical response (disease stability or improvement) for continuation of therapy.
• Statement of Medical Necessity (SMN) precertification forms (Specialty Pharmacy Precertification) for the precertification-required MS medications.

Frequently asked questions

When does Aetna cover Multiple Sclerosis (CPT 36514), and what gets it denied?

Aetna CPB 0264 covers disease-modifying and acute treatments for multiple sclerosis - including alemtuzumab (Lemtrada), mitoxantrone, ocrelizumab (Ocrevus/Ocrevus Zunovo), ublituximab (Briumvi), IV/pulse corticosteroids, and plasma exchange - as medically necessary for appropriately diagnosed relapsing (and, for some agents, CIS or primary progressive) MS when prescribed by or with a neurologist, generally requiring documented disease activity or, for Lemtrada, inadequate response to two or more prior MS drugs. Precertification is explicitly required for Briumvi, Lemtrada, Ocrevus, Ocrevus Zunovo, Tyruko, and Tysabri, and a long list of alternative therapies, biomarkers, and diagnostic tests (e.g., CCSVI venoplasty, cannabinoids, stem cell therapy, serum neurofilament, methotrexate, IVIG) is considered experimental, investigational, or unproven. Coverage criteria include: Alemtuzumab (Lemtrada) must be prescribed by or in consultation with a neurologist.; Alemtuzumab (Lemtrada) FIRST COURSE: medically necessary for members with a diagnosis of a relapsing form of MS (including relapsing-remitting and secondary progressive disease for those who continue to experience relapse) who have had an inadequate response to two or more drugs indicated for MS.; Alemtuzumab (Lemtrada) SUBSEQUENT COURSES: medically necessary for members with a diagnosis of a relapsing form of MS (including relapsing-remitting and secondary progressive disease for those who continue to experience relapse) who have completed at least one previous course of therapy AND treatment will start at least 12 months after the last dose of the prior treatment course.; Alemtuzumab (Lemtrada): members will NOT use Lemtrada concomitantly with other disease-modifying MS agents (Note: Ampyra and Nuedexta are not disease-modifying). Authorization may be granted for pediatric members under 18 years when benefits outweigh risks.; Cladribine, dimethyl fumarate, diroximel fumarate, fingolimod, ozanimod, siponimod, teriflunomide, glatiramer acetate, and ofatumumab: refer to Aetna's Pharmacy Clinical Policy Bulletins (covered under pharmacy benefits).; Interferon beta-1a (Rebif), interferon beta-1b (Betaseron/Extavia), and peginterferon beta-1a (Plegridy): refer to the specific pharmacy clinical policy bulletins.; Intravenous (IV) steroid treatment is medically necessary for ONE of the following: (a) treatment of acute exacerbations of MS when the acute relapse is characterized by functionally disabling symptoms with documented evidence of neurological impairment; OR (b) use of intermittent pulse dose corticosteroids as a maintenance treatment for MS to delay disease progression.; Hospital admission for IV steroid therapy is medically necessary when an acute exacerbation of MS results in ANY of the following severe neurological deficits: acute cerebral symptoms with severe loss of intellectual capacity; acute epileptic seizure(s); acute fulminant MS characterized by headache, vomiting, convulsions and eventually coma, with severe compromise of functioning of the central nervous system; acute pseudobulbar palsy; acute quadriplegia; acute transverse myelitis (or Brown-Sequard syndrome) with loss of function below the level of a suspected lesion in the spinal cord; acute visual loss; OR previous complications from high-dose IV steroids justifying inpatient admission.; Mitoxantrone IV injection must be prescribed by or in consultation with a neurologist.; Mitoxantrone IV injection INITIAL: medically necessary for members diagnosed with a relapsing form of MS (including relapsing-remitting, secondary progressive, and progressive relapsing disease). Note: mitoxantrone is NOT indicated in the treatment of primary progressive MS.; Mitoxantrone IV injection CONTINUATION: medically necessary for members who meet initial criteria AND are experiencing disease stability or improvement, AND there is no evidence of unacceptable toxicity while receiving mitoxantrone therapy.; Natalizumab: see CPB 0751 - Natalizumab (separate policy).; Ocrelizumab (Ocrevus) or ocrelizumab and hyaluronidase-ocsq (Ocrevus Zunovo) must be prescribed by or in consultation with a neurologist.; Ocrelizumab (Ocrevus / Ocrevus Zunovo) INITIAL: medically necessary for ONE of the following: (a) relapsing forms of MS (including relapsing-remitting and secondary progressive disease for those who continue to experience relapse); (b) clinically isolated syndrome (CIS) of MS; OR (c) primary progressive MS (PPMS).; Ocrelizumab (Ocrevus / Ocrevus Zunovo) CONTINUATION: medically necessary for all members (including new members) with relapsing forms of MS, CIS, or PPMS who achieve or maintain a positive clinical response as evidenced by experiencing disease stability or improvement while receiving the requested medication.; Ocrelizumab (Ocrevus / Ocrevus Zunovo): members will NOT use concomitantly with other disease-modifying MS agents (Note: Ampyra and Nuedexta excepted/not disease-modifying). Authorization may be granted for pediatric members under 18 years when benefits outweigh risks.; Plasma exchange / plasmapheresis is medically necessary for members with acute, severe neurological deficits caused by MS who have a poor response to treatment with high-dose glucocorticoids.; Rituximab: see CPB 0314 - Rituximab (separate policy).; Ublituximab-xiiy (Briumvi) must be prescribed by or in consultation with a neurologist.; Ublituximab-xiiy (Briumvi) INITIAL: medically necessary for ONE of the following: (a) relapsing forms of MS (including relapsing-remitting and secondary progressive disease for those who continue to experience relapse); OR (b) clinically isolated syndrome (CIS) of MS.; Ublituximab-xiiy (Briumvi) CONTINUATION: medically necessary for all members (including new members) with relapsing forms of MS or CIS who achieve or maintain a positive clinical response as evidenced by experiencing disease stability or improvement while receiving the requested medication.; Ublituximab-xiiy (Briumvi): members will NOT use Briumvi concomitantly with other disease-modifying MS agents (Note: Ampyra and Nuedexta excepted/not disease-modifying). Authorization may be granted for pediatric members under 18 years when benefits outweigh risks.; DEFINITION - Failure of an adequate trial of therapy for MS is defined as ANY of the following: (1) the member has increasing relapses (defined as two or more relapses in a year, OR one severe relapse associated with either poor recovery or MRI lesion progression); (2) the member has lesion progression by MRI (increased number or volume of gadolinium-enhancing lesions, T2 hyperintense lesions, or T1 hypointense lesions); OR (3) the member has worsening disability (sustained worsening of Expanded Disability Status Scale (EDSS) score or neurological examination findings).; DEFINITION - Intolerance is defined as intolerable side effects despite optimized management strategies.. Applies to 7 codes: 36514, J0202, J2323, J2329, J2350, J2351, J9293. Confirm prior-authorization status with Aetna before scheduling — it is code- and plan-specific, and this policy is not an exact authorization source. Prior authorization status is code-specific; this CPB is not an exact authorization source for every covered code. Check the Aetna precertification list or PA lookup for the exact code and plan context. Documentation: Documented evidence of neurological impairment for acute exacerbations treated with IV steroids.; Evidence of prior medication trials / inadequate response to two or more drugs indicated for MS (for alemtuzumab/Lemtrada).; MRI evidence of lesion progression (gadolinium-enhancing lesions, T2 hyperintense lesions, or T1 hypointense lesions) where used to establish treatment failure.; Expanded Disability Status Scale (EDSS) score or neurological examination findings to document worsening disability where used to establish treatment failure.; Evidence of positive clinical response (disease stability or improvement) for continuation of therapy.; Statement of Medical Necessity (SMN) precertification forms (Specialty Pharmacy Precertification) for the precertification-required MS medications. Policy exclusions and limitations: Alpha-interferon - experimental, investigational, or unproven for MS.; Anti-T-cell monoclonal antibodies other than natalizumab (Tysabri or Tyruko) - experimental, investigational, or unproven for MS.; Anti-lymphocyte globulin - experimental, investigational, or unproven for MS.; APOE genotyping - experimental, investigational, or unproven for MS.; Balloon angioplasty / balloon venoplasty / venous angioplasty with or without stent placement (chronic cerebrospinal venous insufficiency (CCSVI) treatment) - experimental, investigational, or unproven for MS.; Brainstem auditory evoked response for diagnosing MS - experimental, investigational, or unproven.; Cannabis and cannabinoids - experimental, investigational, or unproven for MS.; Cerebrospinal fluid levels of neurofilament as a biomarker of MS - experimental, investigational, or unproven.; Clemastine fumarate for the treatment of chronic demyelinating injury in MS - experimental, investigational, or unproven.; Cooling garment - experimental, investigational, or unproven for MS.; Cosyntropin (Cortrosyn) - experimental, investigational, or unproven for MS.; Cyclosporine (Sandimmune) - experimental, investigational, or unproven for MS.; Dietary interventions (e.g., gluten-free diets, low fat diets, linoleate supplementation to diet, and dietary regimens with polyunsaturated fatty acids) - experimental, investigational, or unproven for MS.; Electronystagmography (in the absence of vertigo or balance disorder) - experimental, investigational, or unproven for MS.; Erythropoiesis stimulating agents (unless criteria are met in CPB 0195 - Erythropoiesis Stimulating Agents) - experimental, investigational, or unproven for MS.; Estrogen receptor beta ligands - experimental, investigational, or unproven for MS.; Ferritin/iron status (blood or CSF) for the diagnosis of MS - experimental, investigational, or unproven.; Functional electrical stimulation (FES) cycling - experimental, investigational, or unproven for MS.; Gamma-interferon - experimental, investigational, or unproven for MS.; gMS DX and gMS Pro EDSS tests for the diagnosis of MS - experimental, investigational, or unproven.; Hyperbaric oxygen - experimental, investigational, or unproven for MS.; Icobrain MS - experimental, investigational, or unproven for MS.; Intravesical vanilloids (e.g., capsaicin and resiniferatoxin) for the treatment of neurogenic lower urinary tract dysfunction in individuals with MS - experimental, investigational, or unproven.; IL-2-toxin - experimental, investigational, or unproven for MS.; IL-10 - experimental, investigational, or unproven for MS.; IL-16 - experimental, investigational, or unproven for MS.; Interleukin-1 gene polymorphisms testing - experimental, investigational, or unproven for MS.; IVIG for multiple sclerosis (relapsing MS and progressive MS) (see CPB 0206 - Parenteral Immunoglobulins) - experimental, investigational, or unproven.; Mesenchymal stem cell therapy - experimental, investigational, or unproven for MS.; Mesenchymal stromal cell-derived neural progenitors - experimental, investigational, or unproven for MS.; Methotrexate - experimental, investigational, or unproven for MS.; MTHFR testing for MS - experimental, investigational, or unproven.; Multiple Sclerosis Disease Activity (MSDA) Test - experimental, investigational, or unproven for MS.; Myelin basic protein peptides - experimental, investigational, or unproven for MS.; Myxovirus resistance protein A (MxA) as a biomarker for MS relapse/treatment response - experimental, investigational, or unproven.; Naltrexone - experimental, investigational, or unproven for MS.; Neurite orientation dispersion and density imaging (NODDI) for evaluation of MS - experimental, investigational, or unproven.; Non-invasive brain stimulation for improvement of cognitive and motor functions in MS - experimental, investigational, or unproven.; Non-pharmacological interventions (biofeedback, hydrotherapy, hypnosis, reflexology, transcranial direct stimulation, transcranial random noise stimulation, and transcutaneous electrical nerve stimulation) for the treatment of chronic pain in MS - experimental, investigational, or unproven.; Optical coherence tomography angiography measurements for MS - experimental, investigational, or unproven.; Optical coherence tomography for screening of member receiving fingolimod (Gilenya) for macular edema - experimental, investigational, or unproven.; Oral myelin (Myloral) - experimental, investigational, or unproven for MS.; Osteopontin as a biomarker for MS - experimental, investigational, or unproven.; Otoacoustic emissions (in the absence of signs of hearing loss) - experimental, investigational, or unproven for MS.; Photopheresis (see CPB 0241 - Extracorporeal Photochemotherapy) - experimental, investigational, or unproven for MS.; Plasmapheresis for chronic or secondary progressive MS (maintenance therapy) - experimental, investigational, or unproven.; Procarin (transdermal histamine) - experimental, investigational, or unproven for MS.; Prolactin - experimental, investigational, or unproven for MS.; Pulsed magnetic field therapy - experimental, investigational, or unproven for MS.; PUVA (psoralen ultraviolet light) - experimental, investigational, or unproven for MS.; Retinal nerve scanning for screening/monitoring persons on fingolimod (Gilenya) - experimental, investigational, or unproven.; Ribavirin - experimental, investigational, or unproven for MS.; Serum / plasma neurofilament as a marker of neuroaxonal injury in early MS and for monitoring disease activity - experimental, investigational, or unproven.; Sildenafil - experimental, investigational, or unproven for MS.; Statins - experimental, investigational, or unproven for MS.; Stem cell transplantation (see CPB 0606 - Stem Cell Transplant for Autoimmune Diseases and Miscellaneous Indications) - experimental, investigational, or unproven for MS.; T-cell receptor therapy - experimental, investigational, or unproven for MS.; T-cell vaccination - experimental, investigational, or unproven for MS.; Total lymphoid irradiation - experimental, investigational, or unproven for MS.; Transcranial brain sonography for predicting disease progression in MS - experimental, investigational, or unproven.; Transforming growth factor (TGF)-beta - experimental, investigational, or unproven for MS.; Tumor necrosis factor antagonists - experimental, investigational, or unproven for MS.; Tympanometry (in the absence of hearing loss) - experimental, investigational, or unproven for MS.; Virtual reality-based therapy for improvement of balance and reduction of fear of falling in individuals with MS - experimental, investigational, or unproven.; Assays of neutralizing antibodies (NABs) against interferon beta (Betaseron) - experimental, investigational, or unproven because its clinical value has not been established.; Measurements of hematopoietic stem and progenitor cell counts as a biomarker of responsiveness to natalizumab - experimental, investigational, or unproven because its clinical value has not been established.; Determination of the expression of the splice variants of the tumor necrosis factor-related apoptosis inducing ligand (TRAIL) and its receptors as a biomarker of responsiveness to interferon-beta - experimental, investigational, or unproven because its clinical value has not been established.; Concomitant use of alemtuzumab (Lemtrada), cladribine (Mavenclad), dimethyl fumarate (Tecfidera), fingolimod (Gilenya), glatiramer acetate (Copaxone, Glatopa), interferon beta, natalizumab (Tysabri, Tyruko), ocrelizumab (Ocrevus, Ocrevus Zunovo), siponimod (Mayzent) and/or teriflunomide (Aubagio) with other disease-modifying MS agents (Note: Ampyra and Nuedexta are not disease-modifying) - experimental, investigational, or unproven because the clinical value has not been established. 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 Multiple Sclerosis?

Confirm prior-authorization status with Aetna before scheduling — it is code- and plan-specific, and this policy is not an exact authorization source. Prior authorization status is code-specific; this CPB is not an exact authorization source for every covered code. Check the Aetna precertification list or PA lookup for the exact code and plan context. Documentation: Documented evidence of neurological impairment for acute exacerbations treated with IV steroids.; Evidence of prior medication trials / inadequate response to two or more drugs indicated for MS (for alemtuzumab/Lemtrada).; MRI evidence of lesion progression (gadolinium-enhancing lesions, T2 hyperintense lesions, or T1 hypointense lesions) where used to establish treatment failure.; Expanded Disability Status Scale (EDSS) score or neurological examination findings to document worsening disability where used to establish treatment failure.; Evidence of positive clinical response (disease stability or improvement) for continuation of therapy.; Statement of Medical Necessity (SMN) precertification forms (Specialty Pharmacy Precertification) for the precertification-required MS medications.

What does Aetna exclude for Multiple Sclerosis?

Policy exclusions and limitations: Alpha-interferon - experimental, investigational, or unproven for MS.; Anti-T-cell monoclonal antibodies other than natalizumab (Tysabri or Tyruko) - experimental, investigational, or unproven for MS.; Anti-lymphocyte globulin - experimental, investigational, or unproven for MS.; APOE genotyping - experimental, investigational, or unproven for MS.; Balloon angioplasty / balloon venoplasty / venous angioplasty with or without stent placement (chronic cerebrospinal venous insufficiency (CCSVI) treatment) - experimental, investigational, or unproven for MS.; Brainstem auditory evoked response for diagnosing MS - experimental, investigational, or unproven.; Cannabis and cannabinoids - experimental, investigational, or unproven for MS.; Cerebrospinal fluid levels of neurofilament as a biomarker of MS - experimental, investigational, or unproven.; Clemastine fumarate for the treatment of chronic demyelinating injury in MS - experimental, investigational, or unproven.; Cooling garment - experimental, investigational, or unproven for MS.; Cosyntropin (Cortrosyn) - experimental, investigational, or unproven for MS.; Cyclosporine (Sandimmune) - experimental, investigational, or unproven for MS.; Dietary interventions (e.g., gluten-free diets, low fat diets, linoleate supplementation to diet, and dietary regimens with polyunsaturated fatty acids) - experimental, investigational, or unproven for MS.; Electronystagmography (in the absence of vertigo or balance disorder) - experimental, investigational, or unproven for MS.; Erythropoiesis stimulating agents (unless criteria are met in CPB 0195 - Erythropoiesis Stimulating Agents) - experimental, investigational, or unproven for MS.; Estrogen receptor beta ligands - experimental, investigational, or unproven for MS.; Ferritin/iron status (blood or CSF) for the diagnosis of MS - experimental, investigational, or unproven.; Functional electrical stimulation (FES) cycling - experimental, investigational, or unproven for MS.; Gamma-interferon - experimental, investigational, or unproven for MS.; gMS DX and gMS Pro EDSS tests for the diagnosis of MS - experimental, investigational, or unproven.; Hyperbaric oxygen - experimental, investigational, or unproven for MS.; Icobrain MS - experimental, investigational, or unproven for MS.; Intravesical vanilloids (e.g., capsaicin and resiniferatoxin) for the treatment of neurogenic lower urinary tract dysfunction in individuals with MS - experimental, investigational, or unproven.; IL-2-toxin - experimental, investigational, or unproven for MS.; IL-10 - experimental, investigational, or unproven for MS.; IL-16 - experimental, investigational, or unproven for MS.; Interleukin-1 gene polymorphisms testing - experimental, investigational, or unproven for MS.; IVIG for multiple sclerosis (relapsing MS and progressive MS) (see CPB 0206 - Parenteral Immunoglobulins) - experimental, investigational, or unproven.; Mesenchymal stem cell therapy - experimental, investigational, or unproven for MS.; Mesenchymal stromal cell-derived neural progenitors - experimental, investigational, or unproven for MS.; Methotrexate - experimental, investigational, or unproven for MS.; MTHFR testing for MS - experimental, investigational, or unproven.; Multiple Sclerosis Disease Activity (MSDA) Test - experimental, investigational, or unproven for MS.; Myelin basic protein peptides - experimental, investigational, or unproven for MS.; Myxovirus resistance protein A (MxA) as a biomarker for MS relapse/treatment response - experimental, investigational, or unproven.; Naltrexone - experimental, investigational, or unproven for MS.; Neurite orientation dispersion and density imaging (NODDI) for evaluation of MS - experimental, investigational, or unproven.; Non-invasive brain stimulation for improvement of cognitive and motor functions in MS - experimental, investigational, or unproven.; Non-pharmacological interventions (biofeedback, hydrotherapy, hypnosis, reflexology, transcranial direct stimulation, transcranial random noise stimulation, and transcutaneous electrical nerve stimulation) for the treatment of chronic pain in MS - experimental, investigational, or unproven.; Optical coherence tomography angiography measurements for MS - experimental, investigational, or unproven.; Optical coherence tomography for screening of member receiving fingolimod (Gilenya) for macular edema - experimental, investigational, or unproven.; Oral myelin (Myloral) - experimental, investigational, or unproven for MS.; Osteopontin as a biomarker for MS - experimental, investigational, or unproven.; Otoacoustic emissions (in the absence of signs of hearing loss) - experimental, investigational, or unproven for MS.; Photopheresis (see CPB 0241 - Extracorporeal Photochemotherapy) - experimental, investigational, or unproven for MS.; Plasmapheresis for chronic or secondary progressive MS (maintenance therapy) - experimental, investigational, or unproven.; Procarin (transdermal histamine) - experimental, investigational, or unproven for MS.; Prolactin - experimental, investigational, or unproven for MS.; Pulsed magnetic field therapy - experimental, investigational, or unproven for MS.; PUVA (psoralen ultraviolet light) - experimental, investigational, or unproven for MS.; Retinal nerve scanning for screening/monitoring persons on fingolimod (Gilenya) - experimental, investigational, or unproven.; Ribavirin - experimental, investigational, or unproven for MS.; Serum / plasma neurofilament as a marker of neuroaxonal injury in early MS and for monitoring disease activity - experimental, investigational, or unproven.; Sildenafil - experimental, investigational, or unproven for MS.; Statins - experimental, investigational, or unproven for MS.; Stem cell transplantation (see CPB 0606 - Stem Cell Transplant for Autoimmune Diseases and Miscellaneous Indications) - experimental, investigational, or unproven for MS.; T-cell receptor therapy - experimental, investigational, or unproven for MS.; T-cell vaccination - experimental, investigational, or unproven for MS.; Total lymphoid irradiation - experimental, investigational, or unproven for MS.; Transcranial brain sonography for predicting disease progression in MS - experimental, investigational, or unproven.; Transforming growth factor (TGF)-beta - experimental, investigational, or unproven for MS.; Tumor necrosis factor antagonists - experimental, investigational, or unproven for MS.; Tympanometry (in the absence of hearing loss) - experimental, investigational, or unproven for MS.; Virtual reality-based therapy for improvement of balance and reduction of fear of falling in individuals with MS - experimental, investigational, or unproven.; Assays of neutralizing antibodies (NABs) against interferon beta (Betaseron) - experimental, investigational, or unproven because its clinical value has not been established.; Measurements of hematopoietic stem and progenitor cell counts as a biomarker of responsiveness to natalizumab - experimental, investigational, or unproven because its clinical value has not been established.; Determination of the expression of the splice variants of the tumor necrosis factor-related apoptosis inducing ligand (TRAIL) and its receptors as a biomarker of responsiveness to interferon-beta - experimental, investigational, or unproven because its clinical value has not been established.; Concomitant use of alemtuzumab (Lemtrada), cladribine (Mavenclad), dimethyl fumarate (Tecfidera), fingolimod (Gilenya), glatiramer acetate (Copaxone, Glatopa), interferon beta, natalizumab (Tysabri, Tyruko), ocrelizumab (Ocrevus, Ocrevus Zunovo), siponimod (Mayzent) and/or teriflunomide (Aubagio) with other disease-modifying MS agents (Note: Ampyra and Nuedexta are not disease-modifying) - experimental, investigational, or unproven because the clinical value has not been established. 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

Related

• All Aetna coverage policies
• Aetna prior-authorization requirements — which codes need PA, by CPT