Clinical Policy Bulletins – Health Care Professionals | Aetna (2023)

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  • 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®")

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CPT only copyright 2015 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 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

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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.

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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.

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FAQs

What is a clinical policy bulletin? ›

Clinical policy bulletins are used by Medicare Advantage plans and commercial payers to describe the services and procedures they cover and under what circumstances, says Denise Wilson, vice president of clinical audit and appeal services at AppealMasters in Towson, Maryland.

What is Aetna policy on 76377? ›

According to CMS policy, 3D rendering with interpretation and reporting of CT, MRI, US, or other tomographic modality (76376, 76377), requires an approved secondary diagnosis. A qualifying procedure for the 3D rendering should also be included on the same date of service, or in the previous three days.

What are clinical policy guidelines? ›

Clinical practice guidelines serve as a framework to provide guidance for clinical decisions and evidence-based best practices, but cannot substitute for the individual clinical judgment brought to each clinical situation by the patient's family physician.

What is CPB in Aetna? ›

Medical Clinical Policy Bulletins (CPBs) detail the services and procedures we consider medically necessary, cosmetic, or experimental and unproven. They help us decide what we will and will not cover. CPBs are based on: Peer-reviewed, published medical journals. A review of available studies on a particular topic.

What are clinical priorities? ›

Clinical priority setting means choosing whom to investigate and what. diagnostic tests to perform; sorting the flow of patients so some are. diagnosed or treated before others; allocating patients to surgery, medical treatment, or watchful observation; and selecting or excluding. patients for a given treatment.

What are Milliman clinical guidelines? ›

The Milliman Care Guidelines span the continuum of patient care providing access to evidence-based knowledge and best practices relevant to patients in a broad range of care settings. This not only assists with decisions for each setting but also facilitates coordination of care and smooth patient transitions.

What is the importance of having clinical policies and guidelines? ›

Clinical guidelines are evidence-informed recommendations intended to optimize patient care. A valid guideline has the potential to influence care outcomes, but for that it needs to be effectively disseminated and implemented so it can inform care processes.

What makes a good clinical guideline? ›

A NICE clinical guideline is developed by following a set method, and using the best available evidence. If there is not enough evidence from clinical research, the advice is based on the views of members of the group developing the clinical guideline (the guideline development group) and other experts.

What are the two types of clinical guidelines? ›

APA develops two types of guidelines: clinical practice guidelines (CPGs) and professional practice guidelines (PPGs). Both types of guidelines are aspirational and consist of recommendations to practitioners to assist in the delivery of high quality care.

Does Aetna follow CMS guidelines? ›

Providers are required to comply with CMS coding and billing requirements. For a provider who treats commercial or Medicaid members, we will pay for covered services in accordance with the member's health plan benefits and applicable laws and regulations.

What is the difference between POS and PPO Aetna? ›

With a POS, or point-of-service plan, you also have one PCP who manages your access to other doctors. However, you can visit doctors out of network but it will cost more. With a PPO, or preferred provider organization plan, you don't need a referral to seek additional care.

What is Aetna PPO called? ›

With the Aetna Open Choice ® PPO plan, members can visit any provider, in network or out, without a referral. But when they stay in network, we'll handle the claims and offer lower, contracted rates. So they save.

What is the difference between 76376 and 76377? ›

CPT code 76376 can be reported when 3D rendering is performed by a radiologist or a specially-trained technologist at the acquisition scanner. CPT code 76377 is reported when the 3D post-processing images are reconstructed on an independent workstation with concurrent physician supervision.

How do I fight Aetna denial? ›

You or your doctor may ask for an "expedited" appeal. Call the toll-free number on your Member ID card or the number on the claim denial letter. If your plan has one level of appeal, we'll tell you our decision no later than 72 hours after we get your request for review.

What are the preventive CPT codes for Aetna? ›

The CPT codes for the annual physical exam are 99381-99397, 99401-99404, 99201-99205 and 99211-99215 with primary diagnosis of preventive.

What are the three most important priorities? ›

And, as author and business consultant Jim Collins famously said, “If you have more than three priorities, you don't have any.” What exactly are these three magical priorities in life? Well, it's simple. Your health, relationships, and purpose.

What are the 5 priorities of care? ›

Box 1. The five priorities for care
  • Recognising that someone is dying.
  • Communicating sensitively with them and others important to them.
  • Involving them and others important to them in decisions.
  • Providing support.
  • Creating an individualised plan of care and delivering it with compassion.
Aug 1, 2014

What are the top 5 priorities? ›

Top 5 Things To Prioritize In Life | Empty Whole
  1. Health.
  2. Family + Relationships.
  3. Self-Improvement.
  4. Money.
  5. Balance.

What is the difference between Milliman and InterQual? ›

InterQual's criteria are, in some respects, stricter than Milliman's, with more precise clinical benchmarks for each level of care. That could mean an uptick in denials for cases in which the patient is borderline for inpatient vs. observation or discharge vs. continued stay.

What is Milliman Risk Score? ›

The Milliman Rx Risk Score is a proprietary scoring algorithm that uses prescription drug history to predict the mortality risk of individuals relative to other individuals of the same age and gender.

What is Milliman and InterQual criteria? ›

Acute inpatient hospitals use Milliman and InterQual criteria to help determine the appropriateness of care. Both sets of criteria are evidence-based screening tools used by providers and insurance companies. They do not substitute for the physician advisors' professional opinions when determining medical necessity.

What is a clinical guidance document? ›

NICE clinical guidelines are recommendations on how healthcare and other professionals should care for people with specific conditions. The recommendations are based on the best available evidence. Clinical guidelines are also important for health service managers and those who commission NHS services.

What is CAPP in healthcare? ›

The Council of Accountable Physician Practices (CAPP) is a coalition of organized multispecialty medical groups and health systems. We believe that improving the health of all Americans requires the reshaping of the care delivery system.

What is Optum behavioral clinical policy? ›

Optum Behavioral Clinical Policies: Criteria that stem from evaluation of new services or treatments or new applications of existing services or treatments, and are used to make determinations regarding proven or unproven services and treatments.

What is a clinical study registry? ›

A patient registry is "an organized system that uses observational study methods to collect uniform data (clinical and other) to evaluate specified outcomes for a population defined by a particular disease, condition or exposure, and that serves a predetermined scientific, clinical or policy purpose."

How can you recognize good clinical guidelines? ›

How can you recognize good clinical guidelines? Good clinical guidelines should be based on up-to-date scientific knowledge, and it should be possible to follow the recommendations in daily medical practice. International uniform standards are now used worldwide for the assessment of clinical guidelines.

What are the two types of CAPP? ›

There are two types of computer aided process planning system. These are as follows : (a) Variant CAPP, and (b) Generative CAPP. A process planning system that creates new plans by retrieving and modifying a standard process plan for a given part family.

What is a CCM patient? ›

CCM is care coordination services done outside of the regular office visit for patients with two or more chronic conditions expected to last at least 12 months or until the death of the patient, and that place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline.

Why is CAPP needed? ›

Computer-aided process planning (CAPP) is the use of computer technology to aid in the process planning of a part or product, in manufacturing. CAPP is the link between CAD and CAM in that it provides for the planning of the process to be used in producing a designed part.

Is UnitedHealthcare and Optum the same? ›

About UnitedHealth Group

UnitedHealth Group has two distinct business platforms: Optum and UnitedHealthcare. This cohesive partnership offers an array of health services and health benefits.

What are the three stages of integrated behavioral healthcare? ›

Levels of Integrated Behavioral Health Care
  • Level One: Minimal Collaboration. ...
  • Level Two: Basic Collaboration At a Distance. ...
  • Level Three: Basic Collaboration On-Site. ...
  • Level Four: Close Collaboration In a Partly Integrated System. ...
  • Level Five: Close Collaboration In a Fully Integrated System.

What are the core values of Optum? ›

Our Values:

Compassion - Walk in the shoes of people we serve and those with whom we work. Relationships - Build trust through collaboration. Innovation - Invent the future, learn from the past. Performance - Demonstrate excellence in everything we do.

What are the 4 types of clinical trials? ›

Types of clinical trials
  • Pilot studies and feasibility studies.
  • Prevention trials.
  • Screening trials.
  • Treatment trials.
  • Multi-arm multi-stage (MAMS) trials.
  • Cohort studies.
  • Case control studies.
  • Cross sectional studies.
Feb 1, 2022

What are the 4 phases of clinical trials? ›

Information For
  • Step 1: Discovery and Development.
  • Step 2: Preclinical Research.
  • Step 3: Clinical Research.
  • Step 4: FDA Drug Review.
  • Step 5: FDA Post-Market Drug Safety Monitoring.
Jan 4, 2018

Which clinical trials pay the most? ›

The therapeutic area can also impact payment — cardiovascular disease, neurology, endocrine, gastrointestinal, and blood disorders trials tend to pay the most.

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