www.aetna.com Open in urlscan Pro
45.223.19.220  Public Scan

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solely responsible for medical advice and treatment of members. Members should
discuss any matters related to their coverage or condition with their treating
provider.

Each benefit plan defines which services are covered, which are excluded, and
which are subject to dollar caps or other limits. Members and their providers
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.

Please note also that the ABA Medical Necessity Guide may be updated and are,
therefore, subject to change.

Medical necessity determinations in connection with coverage decisions are made
on a case-by-case basis. In the event that a member disagrees with a coverage
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Licensee's use and interpretation of the American Society of Addiction
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 * The term precertification here means the utilization review process to
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 * The five character codes included in the Aetna Precertification Code Search
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DENTAL CLINICAL POLICY BULLETINS

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 * Aetna Dental Clinical Policy Bulletins (DCPBs) are developed to assist in
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   Members should discuss any Dental Clinical Policy Bulletin (DCPB) related to
   their coverage or condition with their treating provider.
 * While the Dental Clinical Policy Bulletins (DCPBs) are developed to assist in
   administering plan benefits, they do not constitute a description of plan
   benefits. The Dental Clinical Policy Bulletins (DCPBs) describe Aetna's
   current determinations of whether certain services or supplies are medically
   necessary, based upon a review of available clinical information. Each
   benefit plan defines which services are covered, which are excluded, and
   which are subject to dollar caps or other limits. Members and their providers
   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.
   Aetna's 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). Your benefits plan determines
   coverage. Some plans exclude coverage for services or supplies that Aetna
   considers medically necessary. If there is a discrepancy between this policy
   and a member's plan of benefits, the benefits plan will govern. In addition,
   coverage may be mandated by applicable legal requirements of a State or the
   Federal government.
 * Please note also that Dental Clinical Policy Bulletins (DCPBs) are regularly
   updated and are therefore subject to change.
 * Since Dental Clinical Policy Bulletins (DCPBs) can be highly technical and
   are designed to be used by our professional staff in making clinical
   determinations in connection with coverage decisions, members should review
   these Bulletins with their providers so they may fully understand our
   policies.
 * Under certain plans, if more than one service can be used to treat a covered
   person's dental condition, Aetna may decide to authorize coverage only for a
   less costly covered service provided that certain terms are met.

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MEDICAL CLINICAL POLICY BULLETINS

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Should the following terms and conditions be acceptable to you, please indicate
your agreement and acceptance by selecting the button below labeled "I Accept".

 

 * Aetna Clinical Policy Bulletins (CPBs) are developed to assist in
   administering plan benefits and do not constitute medical advice. Treating
   providers are solely responsible for medical advice and treatment of members.
   Members should discuss any Clinical Policy Bulletin (CPB) related to their
   coverage or condition with their treating provider.
 * While the Clinical Policy Bulletins (CPBs) are developed to assist in
   administering plan benefits, they do not constitute a description of plan
   benefits. The Clinical Policy Bulletins (CPBs) express Aetna's determination
   of whether certain services or supplies are medically necessary, experimental
   and investigational, or cosmetic. Aetna has reached these conclusions based
   upon a review of currently available clinical information (including clinical
   outcome studies in the peer-reviewed published medical literature, regulatory
   status of the technology, evidence-based guidelines of public health and
   health research agencies, evidence-based guidelines and positions of leading
   national health professional organizations, views of physicians practicing in
   relevant clinical areas, and other relevant factors).
 * Aetna makes no representations and accepts no liability with respect to the
   content of any external information cited or relied upon in the Clinical
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   manufacturer, constitute Aetna's opinion and are made without any intent to
   defame. Aetna expressly reserves the right to revise these conclusions as
   clinical information changes, and welcomes further relevant information
   including correction of any factual error.
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   New and revised codes are added to the CPBs as they are updated. When
   billing, you must use the most appropriate code as of the effective date of
   the submission. Unlisted, unspecified and nonspecific codes should be
   avoided.
 * Each benefit plan defines which services are covered, which are excluded, and
   which are subject to dollar caps or other limits. Members and their providers
   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
   discrepancy between a Clinical Policy Bulletin (CPB) and a member's plan of
   benefits, the benefits plan will govern.
 * In addition, coverage may be mandated by applicable legal requirements of a
   State, the Federal government or CMS for Medicare and Medicaid members. 

See CMS's Medicare Coverage Center

 

 * Please note also that Clinical Policy Bulletins (CPBs) are regularly updated
   and are therefore subject to change.
 * Since Clinical Policy Bulletins (CPBs) can be highly technical and are
   designed to be used by our professional staff in making clinical
   determinations in connection with coverage decisions, members should review
   these Bulletins with their providers so they may fully understand our
   policies.
 * While Clinical Policy Bulletins (CPBs) define Aetna's clinical policy,
   medical necessity determinations in connection with coverage decisions are
   made on a case by case basis. In the event that a member disagrees with a
   coverage determination, Aetna provides its members with the right to appeal
   the decision. In addition, a member may have an opportunity for an
   independent external review of coverage denials based on medical necessity or
   regarding the experimental and investigational status when the service or
   supply in question for which the member is financially responsible is $500 or
   greater. However, applicable state mandates will take precedence with respect
   to fully insured plans and self-funded non-ERISA (e.g., government, school
   boards, church) plans.

See Aetna's External Review Program

 

 * 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
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