Your health insurance benefits are governed by the terms of your Aetna health insurance contract. Aetna’s Clinical Policy Bulletins (CPBs) are developed to assist in administering these benefits but do not constitute medical advice. Treating providers are solely responsible for medical advice and treatment of members. Members should discuss any CPBs relevant to their coverage or condition with their treating provider.
While CPBs assist in administering benefits, they do not describe the details of the health plan benefits. CPBs reflect Aetna’s determination of whether certain services or supplies are medically necessary, experimental/investigational, unproven, or cosmetic. Aetna bases its conclusions on a review of currently available clinical information (including clinical outcomes research in peer-reviewed published medical literature, the regulatory status of the technology, evidence-based guidelines of national research and public health agencies, the views of physicians practicing in relevant clinical areas, and other relevant factors).
Aetna makes no representations and assumes no liability with respect to the content of any external information cited or relied upon in CPBs. The discussions, analyses, conclusions, and opinions reflected in the CPBs, including any reference to a specific provider, product, process, or service by trade name, trademark, manufacturer, or otherwise, constitute Aetna’s opinion and are provided without any intent to influence. Aetna reserves the right to modify these conclusions as clinical information changes and welcomes further relevant information, including correction of any factual errors.
CPBs include references to standard HIPAA compliant code sets to support search functionality and facilitate payment for covered services. New and revised codes are added to CPBs as they are updated. When billing, you must use the most appropriate code as of the date of service rendered. Use of unspecified, nonspecific, and not otherwise classified codes should be avoided.
Each benefit plan defines which services are covered, which services are excluded, and which services are subject to limitations. Members and their providers will need to consult the member’s benefit plan to determine if there are any other exclusions or limitations in benefits applicable to this service or supply. The conclusion that a particular service or supply is medically necessary does not constitute a representation or warranty that this service or supply is covered (i.e., will be paid for by Aetna) for a particular member. The member’s benefit plan defines coverage. Some plans exclude coverage for services or supplies that Aetna considers medically necessary. If there is a conflict between the CPB and the member’s benefit plan, the benefit plan governs.
Additionally, coverage may be mandated by applicable State or Federal/CMS requirements for Medicare and Medicaid members.
Please note that the CPBs are updated regularly and therefore are subject to change.
Because the CPBs can be highly technical and are designed to be used by our professional staff in making clinical determinations related to coverage decisions, members should review these Bulletins with their provider so that they can fully understand our policies. In certain instances, your physician may request a peer-to-peer review if they have questions or wish to discuss a prior authorization determination of medical necessity made by our medical directors pursuant to Aetna’s CPBs.
While the CPBs define Aetna’s clinical policy, medical necessity decisions related to coverage decisions are made on a case-by-case basis. In the event a member disagrees with a coverage decision, Aetna provides members with the right to appeal the decision. In addition, a member may have the opportunity for an external independent review of a denial of coverage based on medical necessity or pertaining to experimental/investigational status when the service or supply in question for which the member is financially responsible is $500 or greater. However, applicable state regulations will govern for fully insured and non-ERISA self-funded plans (e.g., government, school board, church).
The five-character code sets included in Aetna’s CPBs are taken from Current Procedural Terminology (CPT®), copyright 2015 American Medical Association (AMA). CPT is developed by the AMA as a listing of descriptive terms and five-character identifying codes and modifiers for reporting medical services and procedures performed by physicians.
Responsibility for the content of Aetna’s CPBs belongs to Aetna and no endorsement by the AMA is intended or should be implied. The AMA disclaims responsibility for any consequences or liability attributable to or related to any use, non-use, or interpretation of information contained or not contained in Aetna’s CPBs. No fee schedules, basic unit values, relative value guides, conversion factors, or scales are included in any part of CPT. Any use of CPT outside of Aetna’s CPBs should refer to the most current Current Procedural Terminology which contains the complete and most up-to-date listing of CPT codes and descriptive terms. Applicable FARS/DFARS apply.
