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Submitted URL:
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Submission: On January 26 via api (January 26th 2023, 12:31:49 pm UTC) from US — Scanned from DE

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Welcome to Aetna’s web and mobile experience. These Aetna Web & Mobile Terms of
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mobile applications) that we operate and that contain a link to these Terms (an
“Application” or together the “Applications”).

By using our Applications you are agreeing to these Terms. Please read them
carefully.

We may modify these Terms at any time by posting the revised Terms on the
Applications. You can determine when these Terms were last revised by referring
to the “LAST UPDATED” legend at the bottom of these Terms. Any modifications
will be effective immediately upon such posting. Your use of or access to the
Applications after such modifications are posted will signify your acceptance of
the modifications and your agreement to be bound by them. Notwithstanding the
foregoing, any modifications to these Terms shall not apply to any dispute
between us arising prior to the date on which we post the revised Terms that
contain such modifications.

Information on the Applications is provided “AS IS” without warranty of any
kind, either express or implied, including, but not limited to, the implied
warranties of merchantability, fitness for a particular purpose, or
non-infringement. Some jurisdictions do not allow the exclusion of implied
warranties, so the above exclusion may not apply to you. The data set forth
herein is for informational purposes only, and no warranty is made that the
information is error-free. Please note that once you leave an Application or
arrive at an Application from another non-Aetna location, either by using a link
we may have provided for your convenience or by specifying your own destination,
Aetna accepts no responsibility for the content, products and/or services
provided at these non-Aetna locations. Aetna does not control, endorse, promote
or have any affiliation with any other website or software application
(including mobile applications) unless expressly stated herein.

LIMITATION OF LIABILITY

IN NO EVENT WILL AETNA BE LIABLE TO ANY PARTY FOR ANY DIRECT, INDIRECT, SPECIAL
OR OTHER CONSEQUENTIAL DAMAGES ARISING OUT OF ANY USE OF THE APPLICATIONS, OR
ANY OTHER HYPER-LINKED WEBSITE OR SOFTWARE APPLICATION (INCLUDING MOBILE
APPLICATIONS), INCLUDING, WITHOUT LIMITATION, ANY LOST PROFITS, BUSINESS
INTERRUPTION, LOSS OF PROGRAMS OR DATA ON YOUR EQUIPMENT, OR OTHERWISE, EVEN IF
WE ARE EXPRESSLY ADVISED OF THE POSSIBILITY OR LIKELIHOOD OF SUCH DAMAGES.

CHANGES TO THE APPLICATIONS

Information may be changed or updated without notice. Aetna has no obligation to
update information presented on the Applications, so information contained
herein may be out of date at any given time. Aetna may also make improvements
and/or changes in the products and/or programs described in this information at
any time without notice.

FORWARD-LOOKING STATEMENTS

Certain information related to financial and operating performance contained on
the Applications is forward-looking. You should consider forward-looking
statements to have been made only as of the date of their original publication
and you should not put undue reliance on forward-looking statements. Those
statements, while included on the Applications for historical reference, speak
only as of the date of their original publication and have not been updated. We
disclaim any intention or obligation to update or revise forward-looking
statements, whether as a result of new information, future events, uncertainties
or otherwise. Forward-looking information is based on management's estimates,
assumptions and projections, and is subject to significant uncertainties and
other factors, many of which are beyond the control of Aetna, CVS Heath
Corporation or any of their affiliates (together, the “Company”). The Private
Securities Litigation Reform Act of 1995 provides a safe harbor for
forward-looking statements made by or on behalf of the Company. By their nature,
all forward-looking statements are not guarantees of future performance or
results and are subject to risks and uncertainties that are difficult to predict
and/or quantify. Actual results may differ materially from those contemplated by
the forward-looking statements due to the risks and uncertainties described in
our Securities and Exchange Commission filings, including those set forth in the
Risk Factors section and under the heading “Cautionary Statement Concerning
Forward-Looking Statements” in our most recently filed Annual Report on Form
10-K and our most recently filed Quarterly Report on Form 10-Q.

PRODUCTS AND SERVICES OFFERINGS

“Aetna” is the brand name used for products and services provided by one or more
of the Aetna group of subsidiary companies.

The product and/or services descriptions, if any, provided on this site are not
intended to constitute offers to sell or solicitations in connection with any
product or service. All products are not available in all areas and are subject
to applicable regulation areas and in many instances may be offered only through
employers or other plan sponsors. Specific products may not be available in both
self-funded and insured forms.

Covered services and preferred benefits are provided under the terms of the
applicable plan contract, including limitations and exclusions.

Anyone interested in a particular product should contact their local Aetna
representative to determine whether the product and/or service is available in
their jurisdiction, and to request a copy of the applicable policy or prospectus
for a complete description of the product and/or service in question.

PAYMENT SERVICE OFFERINGS

A payment service may be available to some members of one or more of the Aetna
Applications. The payment service is powered by our payment service vendor,
Change Healthcare, Inc.

The payment service allows you to make payments to certain health care providers
based on our calculation of your patient responsibility. If you make use of the
payment service, you are responsible for determining the amount that you owe,
which may be less than the patient responsibility shown through our Application.
This may be due to other payments you may have already made directly with the
provider, or other factors that may reduce your outstanding balance with your
health care provider.

You may be able to make payments using a variety of your existing financial
accounts, such as credit card accounts and checking accounts. If you are able to
use an account that is regulated by section 213(d) of the IRS code, such as a
health saving account (HSA) or flexible spending account (FSA), you are
responsible for ensuring the eligibility of the expense under section 213(d).
Not all 213(d) accounts are eligible to be used through the payment service.

By using the payment service to make a payment, you authorize our payment
service vendor to process payment transactions initiated by you through the
payment service using your financial accounts that you designate. You agree that
you are fully responsible for any such transactions and agree to only use
financial accounts where you are an authorized user on the financial account.
You authorize our payment service vendor to make any debits, withdrawals,
charges or transfers from your financial account in the amount you ask for,
including any surcharges or fees that may apply.

In the event that there is an issue with our payment service vendor delivering
your funds to a provider, our vendor will use commercially reasonable efforts to
resolve the issue on your behalf in a timely manner. In certain cases, you can
request a refund of a specific payment. Contact the Aetna contact center to
answer any additional questions. When our payment service vendor needs to return
funds to you, the funds will be returned to the same financial account you
originally used to make the payment.

In no event will we or our payment service vendor be liable to any party for any
direct, indirect, special or other consequential damages arising out of any use
of the payment service. When using the payment service, your entered payment
method information will be protected by us and our payment service vendor. Our
payment service vendor follows major payment card industry (PCI) data security
standards.

THIRD PARTY RESOURCES

The Application may contain links to, or otherwise make available, third-party
sites, services, products, information, content, materials, merchandise,
functionality and/or other resources (“Third Party Resources”). These Third
Party Resources and links and access to them are provided for your convenience
and reference only. We do not control such Third Party Resources and, therefore,
we are not responsible for such Third Party Resources, or any content posted on
or made available by such Third Party Resources. Be aware that we do not
control, and we make no guarantees about, and disclaims any express or implied
representations or warranties about such Third Party Resources, including
without limitation the security of any materials, or the accuracy, relevance,
timeliness, completeness, or appropriateness for a particular purpose of the
information or the resources contained on or made available by such Third Party
Resources or any other Internet sites. We reserve the right to terminate such
links or such access at any time. The fact that we offer such links or access
should not be construed in any way as an endorsement, authorization, or
sponsorship of such Third Party Resources, or any content made available
thereby. Because some Third Party Resources employ automated search results or
otherwise link you to Third Party Resources containing information that may be
deemed inappropriate or offensive, we cannot be held responsible for the
accuracy, copyright compliance, legality, or decency of material contained in or
made available by Third Party Resources, and you hereby irrevocably waive any
claim against us with respect to such Third Party Resources. Your use of any
Third Party Resources is subject to the third party’s terms, conditions and
policies applicable to such products, services or materials (such as Terms of
Service or Privacy Policies of the providers of such products, services or
materials). We are not responsible for the privacy and security of any
information you share with that third party, including your credit card or
payment information. When you elect to receive these services from a third
party, you agree to hold that third party responsible for any unauthorized use
or disclosure of your personal information.

TRADEMARKS

The Aetna logo, Aetna, Aetna Navigator®, Aetna Better Health®, ActiveHealth®,
bSwift®, CareEngine®, Carelink®, DocFind®, Healthagen®, Healthy Merits®,
Innovation Health®, iTriage®, Meritain Health®, PayFlex®, Practice IQ®,
Resources for Living®, WellMatch® and all other trademarks, service marks, trade
names, logos, domain names, URLs and icons (“Marks”) appearing on this website,
registered or not, are the property of Aetna Inc. or their respective owners.
Nothing on this website grants you any right or license to use any of the Marks
on this site without the express written permission of Aetna Inc. or the third
party owners of the Marks. Unauthorized use may violate trademark and other
laws.

OWNERSHIP OF THE APPLICATIONS

The Applications (including any content made available through the Applications)
are the property of Aetna (or its licensors) and are protected by applicable
intellectual property laws. The Applications are licensed, not sold, to you. You
may utilize the Applications only as permitted by these Terms. You may not, and
will not permit any other party to: (1) modify, adapt, alter, translate or
create derivative works of the Applications; (2) use or merge the Applications,
or any component or element thereof, with other software, databases or services
not provided by Aetna; (3) sublicense, distribute, sell or otherwise transfer
the Applications to any third party; (4) use the Applications as a service
bureau, or lease, rent or loan the Applications to any third party; (5) reverse
engineer, decompile, disassemble or otherwise attempt to derive the source code
or structure of the Applications; (6) interfere in any manner with the operation
of the Applications; (7) circumvent, or attempt to circumvent, any electronic
protection measures in place to regulate or control access to the Applications;
(8) create a database by systematically downloading and storing the
Applications; (9) use any robot, spider, site search/retrieval application or
other manual or automatic device to retrieve, index, “scrape” “data mine” or in
any way gather the Applications or reproduce or circumvent the navigational
structure or presentation of the Applications without our express prior written
consent; or (10) use the Applications for any commercial purposes. You agree not
to develop, distribute or sell any software or other functionality capable of
launching, being launched from or otherwise integrated with the Applications.
You may not remove, alter or obscure any copyright notice or any other
proprietary notice that appears on or in the Applications.

SESSION DATA

You consent to the use of tracking technologies on the website to collect and
record your real-time activities and movements across the Applications
throughout your browsing session. You consent to our sharing of your session
data with our vendors. Please review our privacy policy for more information
about our collection, use, and sharing of session data.

TERMINATION

Aetna may suspend or terminate your use of or access to the Applications if you
fail to comply with these Terms. Such suspension or termination may result in
the permanent deletion of your information or other previously available
content.

NOT A SOLICITATION

Nothing in this site should be construed as a solicitation or offer to purchase
coverage from Aetna or any of its affiliated companies.

NOT A SUBSTITUTE FOR PROFESSIONAL HEALTH CARE OR ADVICE

The health information contained in these Applications (for example, Aetna
InteliHealth, Aetna Behavioral Health, and Aetna Dental) is general in nature
and is not a substitute for professional health care. It is not meant to replace
the advice of health care professionals. If you have specific health care needs,
or for complete health information, please see a doctor or other health care
provider.

APPLE-SPECIFIC TERMS AND CONDITIONS

In addition to your agreement with the foregoing Terms, and notwithstanding
anything to the contrary herein, you acknowledge and agree to the following
provisions with respect to your use of any Application that is compatible with
the iOS operating system of Apple Inc. (“Apple”). Apple is not a party to these
Terms and does not own and is not responsible for the Application. Apple is not
providing any warranty for the Application, except if applicable, to refund the
purchase price for it. Apple is not responsible for maintenance or other support
services for the Application and shall not be responsible for any other claims,
losses, liabilities, damages, costs or expenses with respect to the Application,
including, without limitation, any third-party product liability claims, claims
that the Application fails to conform to any applicable legal or regulatory
requirement, claims arising under consumer protection or similar legislation,
and claims with respect to intellectual property infringement. Any inquiries or
complaints relating to the use of the Application, including those pertaining to
intellectual property rights, must be directed to Aetna. The license you have
been granted herein is limited to a non-transferable license to use the
Application on an Apple-branded product that runs Apple's iOS operating system
and is owned or controlled by you, or as otherwise permitted by the Usage Rules
set forth in Apple's App Store℠ Terms of Service. In addition, you agree to
comply with the terms of any third-party agreement that is applicable to you
when using the App, such as your wireless data service agreement. You
acknowledge and agree that Apple and Apple's subsidiaries are third-party
beneficiaries of this Agreement and that, upon your acceptance of the terms and
conditions of this Agreement, Apple will have the right (and will be deemed to
have accepted the right) to enforce this Agreement against you as a third-party
beneficiary thereof. Notwithstanding the immediately preceding sentence, Aetna's
right to enter into, rescind or terminate any variation, waiver or settlement
under these Terms is not subject to the consent of any third party.

LEGAL NOTICES

Aetna is the brand name used for products and services provided by one or more
of the Aetna group of companies, including Aetna Life Insurance Company and its
affiliates (Aetna).

Health benefits and health insurance plans contain exclusions and limitations.

See all legal notices

Also of interest:

*
*
*
*
*

* AETNA APPS

* CAREERS
* FAQs
* GLOSSARY

* ACCESSIBILITY SERVICES
* PLAN DISCLOSURES
* PROGRAM PROVISIONS
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* NEWS AND ANALYSIS

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* LEGAL NOTICES
* PRIVACY CENTER
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* VULNERABILITY DISCLOSURE PROGRAM

YOU ARE NOW BEING DIRECTED TO THE AMA SITE

Links to various non-Aetna sites are provided for your convenience only. Aetna
Inc. and its subsidiary companies are not responsible or liable for the content,
accuracy or privacy practices of linked sites, or for products or services
described on these sites.

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Inc. and its subsidiary companies are not responsible or liable for the content,
accuracy, or privacy practices of linked sites, or for products or services
described on these sites.

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Just enter your mobile number and we’ll text you a link to download the Aetna
Health℠ app from the App Store or on Google Play.

Message and data rates may apply*

Error or missing data. Please check your entries for an error message.
MOBILE NUMBER Please be sure to add a 1 before your mobile number, ex:
19876543210

THIS SEARCH USES THE FIVE-TIER VERSION OF THIS PLAN

Each main plan type has more than one subtype. Some subtypes have five tiers of
coverage. Others have four tiers, three tiers or two tiers. This search will use
the five-tier subtype. It will show you whether a drug is covered or not
covered, but the tier information may not be the same as it is for your specific
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APPLIED BEHAVIOR ANALYSIS MEDICAL NECESSITY GUIDE

By clicking on “I Accept”, I acknowledge and accept that:

The Applied Behavior Analysis (ABA) Medical Necessity Guide helps determine
appropriate (medically necessary) levels and types of care for patients in need
of evaluation and treatment for behavioral health conditions. The ABA Medical
Necessity Guide does not constitute medical advice. Treating providers are
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
determination, member may be eligible for the right to an internal appeal and/or
an independent external appeal in accordance with applicable federal or state
law.

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AETNA® IS PROUD TO BE PART OF THE CVS® FAMILY.

You are now being directed to CVS Caremark® site.

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ASAM TERMS AND CONDITIONS

By clicking on “I accept”, I acknowledge and accept that:

Licensee's use and interpretation of the American Society of Addiction
Medicine’s ASAM Criteria for Addictive, Substance-Related, and Co-Occurring
Conditions does not imply that the American Society of Addiction Medicine has
either participated in or concurs with the disposition of a claim for benefits.

This excerpt is provided for use in connection with the review of a claim for
benefits and may not be reproduced or used for any other purpose.

Copyright 2015 by the American Society of Addiction Medicine. Reprinted with
permission. No third party may copy this document in whole or in part in any
format or medium without the prior written consent of ASAM.

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PRECERTIFICATION LISTS

By clicking on “I accept”, I acknowledge and accept that:

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

* The term precertification here means the utilization review process to
determine whether the requested service, procedure, prescription drug or
medical device meets the company's clinical criteria for coverage. It does
not mean precertification as defined by Texas law, as a reliable
representation of payment of care or services to fully insured HMO and PPO
members.
* Applies to: Aetna Choice® POS, Aetna Choice POS II, Aetna Medicare℠ Plan
(PPO), Aetna Medicare Plan (HMO), all Aetna HealthFund® products, Aetna
Health Network Only℠, Aetna Health Network Option℠, Aetna Open Access® Elect
Choice®, Aetna Open Access HMO, Aetna Open Access Managed Choice®, Open
Access Aetna Select℠, Elect Choice, HMO, Managed Choice POS, Open Choice®,
Quality Point-of-Service® (QPOS®), and Aetna Select℠ benefits plans and all
products that may include the Aexcel®, Choose and Save℠, Aetna Performance
Network or Savings Plus networks. Not all plans are offered in all service
areas.
* All services deemed "never effective" are excluded from coverage. Aetna
defines a service as "never effective" when it is not recognized according to
professional standards of safety and effectiveness in the United States for
diagnosis, care or treatment. Visit the secure website, available through
www.aetna.com, for more information. Click on "Claims," "CPT/HCPCS Coding
Tool," "Clinical Policy Code Search."
* The five character codes included in the Aetna Precertification Code Search
Tool are obtained from Current Procedural Terminology (CPT®), copyright 2022
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 Precertification Code Search Tool
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 Precertification Code Search Tool. 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 Precertification Code
Search Tool should refer to the most 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®")

* CPT only Copyright 2022 American Medical Association. All Rights Reserved.
CPT is a registered trademark of the American Medical Association. You, your
employees and agents are authorized to use CPT only as contained in Aetna
Precertification Code Search Tool solely for your own personal use in
directly participating in health care 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 sue 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.

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 any use, non-use, or interpretation of
information contained or not contained in this product.
* This Agreement will terminate upon notice if you violate its terms. The AMA
is a third party beneficiary to this Agreement.
* Should the foregoing terms and conditions be acceptable to you, please
indicate your agreement and acceptance by selecting the button labeled "I
Accept".
* The information contained on this website and the products outlined here may
not reflect product design or product availability in Arizona. Therefore,
Arizona residents, members, employers and brokers must contact Aetna directly
or their employers for information regarding Aetna products and services.
* This information is neither an offer of coverage nor medical advice. It is
only a partial, general description of plan or program benefits and does not
constitute a contract. In case of a conflict between your plan documents and
this information, the plan documents will govern.

I accept

DENTAL CLINICAL POLICY BULLETINS

By clicking on “I accept”, I acknowledge and accept that:

* 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
person's dental condition, Aetna may decide to authorize coverage only for a
less costly covered service provided that certain terms are met.

I accept

MEDICAL CLINICAL POLICY BULLETINS

By clicking on “I accept”, I acknowledge and accept that:

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
Policy Bulletins (CPBs). The discussion, analysis, conclusions and positions
reflected in the Clinical Policy Bulletins (CPBs), including any reference to
a specific provider, product, process or service by name, trademark,
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.
* 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.

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
any use, non-use, or interpretation of information contained or not contained in
this product.

This Agreement will terminate upon notice if you violate its terms. The AMA is a
third party beneficiary to this Agreement.

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

The information contained on this website and the products outlined here may not
reflect product design or product availability in Arizona. Therefore, Arizona
residents, members, employers and brokers must contact Aetna directly or their
employers for information regarding Aetna products and services.

This information is neither an offer of coverage nor medical advice. It is only
a partial, general description of plan or program benefits and does not
constitute a contract. In case of a conflict between your plan documents and
this information, the plan documents will govern.

I accept

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