Aetna Clinical Policy Bulletins (CPBs) are integral documents designed to assist in the administration of healthcare plan benefits. It is crucial to understand that while these bulletins are valuable resources, they are not intended to provide medical advice. The responsibility for medical advice and the treatment of patients rests solely with the treating healthcare providers. Patients are encouraged to discuss any CPB related to their coverage or health condition directly with their physicians to fully understand its implications for their care.
CPBs serve as guides for Aetna in determining whether specific medical services or supplies meet the criteria for medical necessity, or if they are considered experimental, investigational, unproven, or cosmetic. These determinations are made by Aetna following a thorough review of current clinical evidence. This evidence includes clinical outcome studies published in peer-reviewed medical literature, the regulatory status of relevant technologies, evidence-based guidelines from public health and health research agencies, positions of leading national health professional organizations, insights from practicing physicians in pertinent clinical fields, and other pertinent factors.
Aetna explicitly states that it makes no endorsements or bears any liability concerning the content of external sources referenced within the CPBs. The discussions, analyses, conclusions, and stances presented in these bulletins, including any mentions of specific providers, products, processes, or services by name, trademark, or manufacturer, reflect Aetna’s professional opinion and are not intended to be defamatory in any way. Aetna retains the right to modify these conclusions as new clinical information emerges and welcomes additional relevant information, including corrections of any factual inaccuracies.
To enhance usability and streamline administrative processes, CPBs incorporate references to standard HIPAA compliant code sets. These codes are intended to aid in search functionalities and to facilitate accurate billing and payment for covered services. As codes are updated or revised, CPBs are correspondingly updated to reflect these changes. It is imperative to use the most accurate and effective code at the time of billing submission, avoiding the use of unlisted, unspecified, and nonspecific codes whenever possible to ensure claim accuracy and efficiency.
The specifics of healthcare coverage, including covered services, exclusions, and any applicable limitations such as dollar caps, are defined by each individual benefit plan. Members and healthcare providers must consult the member’s specific benefit plan documentation to ascertain whether any exclusions or limitations apply to a particular service or supply. It is important to note that a determination of medical necessity by Aetna does not automatically guarantee coverage (i.e., payment by Aetna) for a particular member. Coverage is ultimately governed by the member’s specific benefit plan. Some plans may indeed exclude coverage for services or supplies that Aetna deems medically necessary. In cases where discrepancies arise between a CPB and a member’s benefit plan, the provisions of the benefit plan will take precedence.
Furthermore, it’s important to recognize that coverage mandates can also arise from applicable legal requirements at the state, federal, or CMS level, particularly for Medicare and Medicaid beneficiaries. For detailed information, individuals are encouraged to consult the CMS’s Medicare Coverage Center.
See CMS’s Medicare Coverage Center
Given that Clinical Policy Bulletins are regularly reviewed and updated, they are subject to change. Their technical nature necessitates careful review, especially for members who need to understand coverage decisions. It is recommended that members discuss these bulletins with their healthcare providers to fully grasp the policies and their potential impact on care decisions. In situations where a physician has questions or wishes to discuss a medical necessity precertification determination made by Aetna’s medical director, a peer-to-peer review process is available for further clarification and discussion.
While CPBs establish Aetna’s clinical policy guidelines, it is important to remember that medical necessity determinations are made on a case-by-case basis when coverage decisions are being considered. Aetna provides a formal appeals process for members who disagree with a coverage determination. Additionally, members may have the option for an independent external review of coverage denials, particularly those based on medical necessity or experimental/investigational status, especially when the member’s financial responsibility is $500 or greater. State mandates may take precedence for fully insured plans and self-funded non-ERISA plans, such as those for government entities, school boards, or churches. Further details on this process can be found in Aetna’s External Review Program.
See Aetna’s External Review Program
The five-character codes within Aetna CPBs are derived from Current Procedural Terminology (CPT®), copyrighted by the American Medical Association (AMA). CPT codes are used for reporting medical services and procedures. Aetna is responsible for the content of its CPBs, and no endorsement by the AMA is implied or intended. The AMA disclaims any liability related to the use, interpretation, or application of information within Aetna CPBs. CPT codes are intended for use within CPBs and any use outside of this context should refer to the most current CPT manual.
LICENSE FOR USE OF CURRENT PROCEDURAL TERMINOLOGY, FOURTH EDITION (“CPT®”)
CPT copyright 2015 American Medical Association. All Rights Reserved. CPT is a registered trademark of the American Medical Association.
Use of CPT within Aetna CPBs is authorized solely for personal use in healthcare programs administered by Aetna, Inc. The AMA retains all rights to CPT. Unauthorized uses, such as making copies for resale, transferring copies, creating derivative works, or any commercial use, are prohibited. For any use outside of Aetna CPBs, a license must be obtained directly from the AMA.
Go to the American Medical Association Web site
U.S. Government Rights
This product includes CPT, which is commercial technical data and/or software developed at private expense by the American Medical Association. U.S. Government rights regarding this data are restricted under various DFARS and FAR clauses applicable to Department of Defense and non-Department of Defense federal procurements respectively.
Disclaimer of Warranties and Liabilities.
CPT is provided “as is” without warranties, including merchantability and fitness for a particular purpose. The AMA does not practice medicine or dispense medical services. Aetna is responsible for the content of this product, and AMA endorsement is not implied. The AMA disclaims liability from the use or interpretation of this product. The agreement is terminable upon violation of terms, and the AMA is a third-party beneficiary.
For Arizona residents, product design and availability may vary. Arizona residents should contact Aetna directly for product information. This information is not an offer of coverage or medical advice and is a general description of benefits, not a contract. Plan documents govern in case of conflict.
