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Submitted URL:
https://aetna.app.link/U5XxO0tmoub?cid=eml_m_1620847&campaign=eml_m_1620847&ss=appstore
Effective URL:
https://www.aetna.com/individuals-families/using-your-aetna-benefits/aetna-mobile.html?cid=eml_m_1620847&campaign=eml_...
Submission: On April 23 via api (April 23rd 2023, 4:30:48 pm UTC) from CH — Scanned from DE

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Each benefit plan defines which services are covered, which are excluded, and
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The conclusion that a particular service or supply is medically necessary does
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Please note also that the ABA Medical Necessity Guide may be updated and are,
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Licensee's use and interpretation of the American Society of Addiction
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Tool," "Clinical Policy Code Search."
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by the American Medical Association (AMA). CPT is developed by the AMA as a
listing of descriptive terms and five character identifying codes and
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must be obtained through the American Medical Association, CPT Intellectual
Property Services, 515 N. State Street, Chicago, Illinois 60610. Applications
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* This product includes CPT which is commercial technical data and/or computer
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are subject to the limited rights restrictions of DFARS 252.227-7015(b)(2)
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DENTAL CLINICAL POLICY BULLETINS

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* Aetna Dental Clinical Policy Bulletins (DCPBs) are developed to assist in
administering plan benefits and do not constitute dental advice. Treating
providers are solely responsible for dental advice and treatment of members.
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
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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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reflected in the Clinical Policy Bulletins (CPBs), including any reference to
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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.
* CPBs include references to standard HIPAA compliant code sets to assist with
search functions and to facilitate billing and payment for covered services.
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
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.
The AMA disclaims responsibility for any consequences or liability
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
acknowledge that AMA holds all copyright, trademark and other rights in CPT.

Any use not authorized herein is prohibited, including by way of illustration
and not by way of limitation, making copies of CPT for resale and/or license,
transferring copies of CPT to any party not bound by this agreement, creating
any modified or derivative work of CPT, or making any commercial use of CPT.
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.

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This product includes CPT which is commercial technical data and/or computer
data bases and/or commercial computer software and/or commercial computer
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private expense by the American Medical Association, 515 North State Street,
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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
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Supplements, for non-Department of Defense Federal procurements.

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