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will need to consult the member's benefit plan to determine if there are any
exclusions or other benefit limitations 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 determines coverage. Some plans exclude coverage for
services or supplies that Aetna considers medically necessary. If there is a
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* Please note also that Clinical Policy Bulletins (CPBs) are regularly updated
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* The five character codes included in the Aetna Clinical Policy Bulletins
(CPBs) are obtained from Current Procedural Terminology (CPT®), copyright
2015 by the 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.
* The responsibility for the content of Aetna Clinical Policy Bulletins (CPBs)
is with Aetna and no endorsement by the AMA is intended or should be implied.
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attributable or related to any use, nonuse or interpretation of information
contained in Aetna Clinical Policy Bulletins (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 Clinical Policy Bulletins
(CPBs) should refer to the most current Current Procedural Terminology which
contains the complete and most current listing of CPT codes and descriptive
terms. Applicable FARS/DFARS apply.

LICENSE FOR USE OF CURRENT PROCEDURAL TERMINOLOGY, FOURTH EDITION ("CPT®")

You, your employees and agents are authorized to use CPT only as contained in
Aetna Clinical Policy Bulletins (CPBs) solely for your own personal use in
directly participating in healthcare programs administered by Aetna, Inc. You
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Any use not authorized herein is prohibited, including by way of illustration
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transferring copies of CPT to any party not bound by this agreement, creating
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License to use CPT for any use not authorized herein must be obtained through
the American Medical Association, CPT Intellectual Property Services, 515 N.
State Street, Chicago, Illinois 60610. Applications are available at the
American Medical Association Web site, www.ama-assn.org/go/cpt.

Go to the American Medical Association Web site

U.S. Government Rights

This product includes CPT which is commercial technical data and/or computer
data bases and/or commercial computer software and/or commercial computer
software documentation, as applicable which were developed exclusively at
private expense by the American Medical Association, 515 North State Street,
Chicago, Illinois, 60610. U.S. Government rights to use, modify, reproduce,
release, perform, display, or disclose these technical data and/or computer data
bases and/or computer software and/or computer software documentation are
subject to the limited rights restrictions of DFARS 252.227-7015(b)(2) (June
1995) and/or subject to the restrictions of DFARS 227.7202-1(a) (June 1995) and
DFARS 227.7202-3(a) (June 1995), as applicable for U.S. Department of Defense
procurements and the limited rights restrictions of FAR 52.227-14 (June 1987)
and/or subject to the restricted rights provisions of FAR 52.227-14 (June 1987)
and FAR 52.227-19 (June 1987), as applicable, and any applicable agency FAR
Supplements, for non-Department of Defense Federal procurements.

Disclaimer of Warranties and Liabilities.

CPT is provided "as is" without warranty of any kind, either expressed or
implied, including but not limited to the implied warranties of merchantability
and fitness for a particular purpose. No fee schedules, basic unit, relative
values or related listings are included in CPT. The American Medical Association
(AMA) does not directly or indirectly practice medicine or dispense medical
services. The responsibility for the content of this product is with Aetna, Inc.
and no endorsement by the AMA is intended or implied. The AMA disclaims
responsibility for any consequences or liability attributable to or related to
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