Aetna payment policy. Note: Requires Precertification:.
Aetna payment policy The MiVu mucosal integrity testing system is considered experimental, investigational, or unproven for the diagnosis of gastro-esophageal reflux disease (GERD). In the event that a member disagrees with a Oct 24, 2024 · Policy Scope of Policy. 5. Caloric vestibular testing; Dynamic or head shaking acuity testing Banner|Aetna is working better together with you to create healthcare that’s low cost, local and tailored just to you. Aetna considers nutritional counseling a medically necessary preventive service for children and adults who are obese, and for adults who are overweight and have other cardiovascular disease risk factors (hypertension, dyslipidemia, impaired fasting glucose, or Policy Scope of Policy. Precertification of esketamine nasal spray (Spravato) is required of all Aetna participating providers and members in applicable plan designs. S. Policy Scope of Policy. INFUSE Bone Graft (Bone Morphogenic Protein-2) Aetna considers the INFUSE Bone Graft medically necessary for lumbar spinal fusion procedures in skeletally mature persons who meet the following criteria: Dec 11, 2024 · Policy Scope of Policy. This Clinical Policy Bulletin addresses diagnostic and treatment modalities and associated accessories and supplies for obstructive sleep apnea in adults. 850 Philad elphia, PA 19103 . Aetna Better Health® Kids 1425 Union Meeting Road Blue Bell, PA 19422 OCTOBER 6, 2022 . Find tools and guidelines for Aetna health plans and providers. Diagnosis. This Clinical Policy Bulletin addresses endothelial cell photography. This Clinical Policy Bulletin addresses electric tumor treatment fields. Symptoms are not adequately controlled by empiric conservative therapy; and Policy Scope of Policy. This Clinical Policy Bulletin addresses daratumumab for commercial medical plans. An updated telemedicine policy will be shared in Q4 2023. This Clinical Policy Bulletin addresses cryoablation. Rad. Aetna considers liver transplantation medically necessary for the indications listed below in Section I. This Clinical Policy Bulletin addresses color-flow doppler echocardiography in adults. This Clinical Policy Bulletin addresses early intervention programs. Refer to Use a credit card, debit card or pay directly from your checking or savings account using our secure payment system. Achauer BM. ** Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. In the event that a member disagrees with a coverage determination, Aetna provides its members with the right to appeal the decision. Related Policies. Aetna considers chiropractic services medically necessary when all of the following criteria are met:. Estrogen. Electronic Solutions. We regularly revise our clinical, payment and coding policy positions as part of our ongoing policy review processes. Contact us; Español; Contact include references to standard HIPAA compliant code sets to assist with search functions and to facilitate billing and payment for covered services. All at an affordable price. This Clinical Policy Bulletin addresses erythropoiesis stimulating agents for commercial medical plans. Rockville, MD: AHCPR; April 1993. Aetna considers the following tests medically necessary for diagnosing obstructive sleep apnea (OSA) in adults aged 18 years and older when criteria are met: Aetna CVS Health ACA plan members, do you have questions about paying your bill, renewing your plan or finding other member tools and resources? If you miss a payment, your plan may be cancelled. Individuals & Families Clinical Policy Bulletins. Aetna considers intraoperative radiation therapy (IORT) medically necessary for the treatment of cervical cancer, colorectal cancer, soft tissue sarcoma (including retroperitoneal sarcoma), and uterine cancer. 15 Joining our network Claims payment policy Policy Scope of Policy. This Clinical Policy Bulletin addresses tuberculosis testing. This Clinical Policy Bulletin addresses biofeedback. Aetna considers endothelial cell photography medically necessary for members with any of the following indications:. No. Aetna considers single photon emission computed tomography (SPECT) medically necessary for any of the following indications: Policy Scope of Policy. This Clinical Policy Bulletin addresses peripheral atherectomy and thrombectomy devices. This Clinical Policy Bulletin addresses transvaginal ultrasonography. This Clinical Policy Bulletin addresses pembrolizumab (Keytruda) for commercial medical plans. This Clinical Policy Bulletin addresses influenza vaccine. Jun 12, 2024 · Policy Scope of Policy. Other topics . Policy Limitations and Exclusions . Learn how Aetna pays for telemedicine, telehealth, direct patient contact, and other health care services. “In this case, Aetna ended up being receptive to our [feedback]. Aetna considers proton beam radiotherapy (PBRT) medically necessary for the curative treatment of any of the following tumors: Primary CNS tumors; or Aetna Better Health® of Pennsylvania Aetna Better Health® Kids . Effective for dates of service beginning July 31, 2018: Bundled Facility Payment Policy-Ambulance Services Bundled to the Facility Admission -#1 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. Guidelines for Determining Coverage | Clinical Policy Bulletins | Medicare | Payment Policy Aetna also released an updated version of its Telemedicine and Direct Patient Contact Payment Policy that also went into effect Dec. Aetna considers magnetic resonance imaging (MRI) of the breast medically necessary for any of the following:. Aetna considers proton beam radiotherapy (PBRT) medically necessary for the curative treatment of any of the following tumors: Primary CNS tumors; or Policy Scope of Policy. We won’t send you reminders to pay your premium. This Clinical Policy Bulletin addresses leadless cardiac pacemaker. Preventive Services Task Force (USPSTF) and the American College of Obstetricians and Gynecologists (ACOG), Aetna considers annual cervical cancer screening with conventional or liquid-based Papanicolaou Policy Scope of Policy. Aetna considers safety enclosures for beds medically necessary DME only when the member's condition places them Nov 9, 2024 · This Clinical Policy Bulletin addresses high intensity focused ultrasound. , Micra Transcatheter Pacing System, Aveir Transcatheter Pacing System) medically necessary when both of the following criteria are met:. Aetna considers specific allergy testing medically necessary for members with clinically significant allergic history of symptoms when all of the following criteria are met:. Claims, Payment & Reimbursement. Note: This CPB does not address therapeutic drug monitoring, drug testing in the emergency room, or monitoring of persons prescribed drugs with abuse potential that are prescribed outside of a pain management program or substance use Policy Scope of Policy. You can also ask for Extra Help. This Clinical Policy Bulletin addresses transcranial magnetic stimulation and cranial electrical stimulation. Non-Cardiac Indications. Aetna considers the Mantoux tuberculin skin-test a medically necessary preventive service, according to guidelines from the Advisory Council for the Elimination of Tuberculosis. Patient Aug 21, 2024 · Policy Scope of Policy. Note: eviCore guidelines undergo a formal review annually; however, eviCore reserves the right to Policy Scope of Policy. As defined in Aetna commercial policies, health care services are not medically necessary when they are more costly than alternative services that are at least as likely to Nov 5, 2024 · Policy Scope of Policy. The member has symptomatic paroxysmal or permanent 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. New York, NY: Empire Medicare Services; November 17, 1978. 1, 2023, and is accessible on the Background. Medicare Part B Medical Policy. As a bridge to transplant for members who are awaiting heart transplantation (see CPB 0586 - Heart Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. Feig SA, Hendrick RE. This Clinical Policy Bulletin addresses magnetic resonance imaging (MRI) of the breast. With or without contrast materials for members who have had a recent (within the past year) conventional mammogram and/or Scope of Policy. This Clinical Policy Bulletin addresses ultrasound for pregnancy. Aetna Ace bandages, splints, foam cervical collars, etc. This Clinical Policy Bulletin addresses testosterone undecanoate (Aveed) injection for commercial medical plans. Aetna considers the following indications medically necessary unless otherwise stated: Ultrasounds are considered not medically necessary if done solely to determine the fetal sex or to provide parents with a view and photograph of the Policy Scope of Policy. Pacemaker Monitors. This Clinical Policy Bulletin addresses physical therapy. Aetna does not cover back school for occupational purposes and other return to work/reintegration or vocational programs including work hardening programs as they are considered vocational training, and not treatment of illness or injury. Effects of exercise and cardiac rehabilitation on cardiovascular outcomes. Aetna considers the following skin and soft tissue substitute products medically necessary (unless otherwise specified) for wound care according to the criteria indicated below. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. 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). . This Clinical Policy Bulletin addresses Mohs micrographic surgery. This Clinical Policy Bulletin addresses single photon emission computed tomography (SPECT). Prefabricated Volar Wrist Brace. She attended TMA’s meeting with Aetna after receiving incorrect payments from the insurer. Adolescents 12 years of age or older and adults with either:. Med Clin North Am. Hospitalized members receiving Veklury for the treatment of COVID-19 will be managed according to the member’s inpatient Aetna's medical necessity criteria for external infusion pumps for diabetes have been adapted from Medicare national policy on external insulin infusion pumps, as outlined in CMS's Coverage Issues Manual Section 60-14. Detection and diagnosis. Provider Dispute Resolution process, and Aetna Payment Policies. The member has a neuromusculoskeletal disorder; and The medical necessity for treatment is clearly documented; and Improvement is documented within the Apr 22, 2024 · Policy Scope of Policy. This Clinical Policy Bulletin addresses bupivacaine liposome (Exparel). This Clinical Policy Bulletin addresses occupational therapy. Sep 16, 2024 · Policy Limitations and Exclusions. 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. This Clinical Policy Bulletin addresses skin and soft tissue substitutes. 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). Skip to content. For plans without this exclusion, androgens and anabolic steroids as well as other medical interventions for performance enhancement are not covered because performance enhancement of non-diseased individuals is not considered treatment of disease or injury. Please read this manual carefully. This is a government 4 days ago · 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. Medically Necessary. The above policy is based on the following references: America Academy of Pediatrics Committee on Infectious Diseases. Aetna considers the following interventions medically necessary: Esophagogastroduodenoscopy (EGD)/upper endoscopy for high-risk screening in any of the following: Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin addresses manipulation under general anesthesia. Join; Renew Policy Scope of Policy. Jan 14, 2025 · Number: 0892. 1425 Union Meeting Road Blue Bell, PA 19422 CLINICAL PAYMENT, CODING AND POLICY CHANGES . It contains monthly payment slips for you to send in with your payments. Sign up or log in. Aetna considers transvaginal ultrasonography (TV-US) medically necessary for a number of indications: Assessment of a pelvic Policy Scope of Policy. B. Call 1-855-651-4856 (TTY: 711), 24 hours a day, 7 days a week, to talk about your premium payment options. 93-0550. The above policy is based on the following references: Ades PA, Coello CE. Note: Requires Precertification: Aetna Better Health ® of Pennsylvania 2000 Market Street Ste. This Clinical Policy Bulletin addresses nerve conduction studies. For Aetna's policy on scoliosis braces, see CPB 0398 - Idiopathic Scoliosis. Precertification of testosterone undecanoate injection (Aveed) is required of all Aetna participating providers and members in applicable plan designs. Jul 12, 2024 · Policy Scope of Policy. Aetna considers high intensity focused ultrasound (HIFU) medically necessary for radio-recurrent prostate cancer in the absence of metastatic disease. and its subsidiary companies are not responsible or liable for the content, accuracy, or privacy practices of linked sites, or for products or services Policy Scope of Policy. Medical Necessity. Lasers in plastic surgery: Current practice. This Clinical Policy Bulletin addresses cervical cancer screening and diagnosis. g. Your agreement requires you to comply with Aetna policies and procedures including those contained in this manual. Agency for Healthcare Policy and Research (AHCPR). 5 Back to top . Aetna considers biofeedback medically necessary for the following conditions: Cancer pain; Chronic constipation secondary to dyssynergic defecation as confirmed by anorectal manometry; Fecal incontinence; Irritable bowel syndrome Policy Scope of Policy. Note on Definition of Intensity Modulated Radiation Therapy (IMRT): For purposes of this policy, to qualify as IMRT, radiation therapy requires highly sophisticated treatment planning utilizing numerous beamlets to generate dosimtery in accordance with assigned dose requirements to the tumor and organs at risk. For ambulatory recording of EEG to facilitate subsequent expert (Note: Payment for the modifications may not exceed the limit set for the inserts for which the individual is entitled). Aetna considers outpatient (Phase II) cardiac rehabilitation medically necessary when the eligibility and program description are met as described below. And you’d have to wait until Open Enrollment to get a new plan unless you qualify for a Special Enrollment Period. Note: The criteria outlined in this policy is only applicable to coverage in the outpatient setting. CPB 0016 - Back Pain - Invasive Procedures; CPB 0784 - Blood and Adipose Product Injections for Selected Indications Oct 11, 2024 · Policy Scope of Policy. NEW POLICY UPDATES – JULY 31, 2018: CLINICAL PAYMENT, CODING AND POLICY CHANGES . Precertification of erythropoiesis stimulating agents (Aranesp, Epogen, Procrit, Retacrit, Mircera) is required of all Aetna participating providers Aug 23, 2024 · Note: Upon medical review, exceptions can be made to criterion 2 in members with spinal cord injury and brain damage. This Clinical Policy Bulletin addresses implantable hormone pellets for commercial medical plans. 2000;84(1):251-265 Policy Scope of Policy. For medical necessity criteria for peripheral atherectomy, see eviCore Healthcare Peripheral Vascular Intervention Clinical Guidelines. This Clinical Policy Bulletin addresses proton beam, neutron beam, and carbon ion radiotherapy. Examples of brand names of electric hospital beds include the Deluxe Franklin Bed. This Clinical Policy Bulletin addresses hip arthroplasty. Laboratory test panels may also be considered experimental, investigational, or unproven if they include standard tests that are performed for persons without specific signs and symptoms warranting performance of the test and for Policy Scope of Policy. Erythrocytosis of undetermined etiology where the hematocrit is 55 % or higher; or Hemochromatosis (including hereditary hemochromatosis); or Individuals receiving Policy Scope of Policy. Aetna considers an Food and Drug Administration (FDA)-approved metal-on-metal, metal-on-plastic, ceramic-on-plastic, or ceramic-on-ceramic total hip arthroplasty (THA) prosthesis medically necessary for adult members when the following criteria are met: 4 days ago · Payment plans are available for premium payments. This Clinical Policy Bulletin addresses bone and tendon graft substitutes and adjuncts. Skip to main content. New appointment wait time standards coming in January . LEGAL RESOURCES Aetna’s Payment Policy of EKG 12-Lead Service Important Message Regarding Aetna’s Payment Policy of EKG 12-Lead Service (CPT 93010) When Billed With an Emergency Room Evaluation & Management (E&M) Code (CPT 99281-99285) Effective August 12, 2006 Aetna will consider claims for. Precertification of intravenous golimumab (Simponi Aria) is required of all Aetna participating providers and Jun 28, 2024 · Policy Scope of Policy. Aetna considers a Food and Drug Administration (FDA)-approved ventricular assist device (VAD) medically necessary for any of the following FDA-approved indications:. Payment Estimator. For Medicare criteria, see Medicare Part B Criteria. Experimental, Investigational, or Unproven. This Clinical Policy Bulletin addresses chronic vertigo. Aetna considers occupational therapy (OT) medically necessary for the following indications, unless otherwise specified: Short-term OT in selected cases when this care is prescribed by a physician, and the following criteria are met: Policy Scope of Policy. Reminder about OD processing time frames. 1997;99(5):1442-1450. Aetna Clinical Policy Bulletins (CPBs) are developed to assist in administering plan benefits and do not constitute medical advice. Aetna considers the following neuropsychological and psychological testing medically necessary (unless otherwise stated) when criteria are met: Policy Scope of Policy. This Clinical Policy Bulletin addresses qualitative and quantitative polymerase chain reaction (PCR) testing. Aetna considers the following procedures as medically necessary (unless otherwise specified) for chronic vertigo: Diagnosis and Evaluation of Chronic Vertigo or Ménière's Disease. Aetna considers the following medically necessary: Arthroscopic knee surgery Aetna considers sensory integration therapy and auditory integration therapy (also known as auditory integration training) experimental, investigational, or unproven for the management of persons with various communication, behavioral, emotional, and learning disorders and for all other indications. Precertification of intravenous golimumab (Simponi Aria) is required of all Aetna participating providers and members in Aetna also released an updated version of its Telemedicine and Direct Patient Contact Payment Policy that also went into effect Dec. Esserman L, Kerlikowske K. Mid-level practitioners policy — E&M services Effective September 1, 2022, we will no longer pay codes G0402, G0438 and G0439 at 100% when billed with E&M Current Procedural Terminology® (CPT®)* codes by nurse practitioners, physician assistants, certified nurse midwives and clinical nurse specialists. NEW POLICY UPDATES – EFFECTIVE APRIL 1, 2021 . Aetna considers cryoablation medically necessary for the following: Adrenal gland metastases (up to 4-cm in size) Cervical intraepithelial neoplasia Policy. Find eligible CPT/HCPCS codes, modifiers, and policy guidelines for commercial and It includes policies and procedures. Dispute & Appeal Process. This Clinical Policy Bulletin addresses electroretinography. This Clinical Policy Bulletin addresses drug testing in pain management and substance use disorder treatment. 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. Aetna considers transcranial magnetic stimulation (TMS) in a healthcare provider’s office medically Policy Scope of Policy. Aetna considers manipulation under general anesthesia (MUA) medically necessary for the following indications: Arthrofibrosis of knee following total knee arthroplasty, knee surgery, or fracture (see Appendix); or Policy Scope of Policy. The selection criteria are listed below. Your This policy addresses our guidelines regarding payment for telehealth, telemedicine, direct patient contact, care plan oversight, concierge medicine, and missed appointments. This Clinical Policy Bulletin addresses urological supplies. We regularly augment our clinical, payment and coding policy positions as part of our ongoing policy review processes. Aetna considers ambulatory electroencephalography (EEG) with or without home video monitoring medically necessary for any of the following conditions, where the member has had a recent (within the past 12 months) neurologic Policy Scope of Policy. Alloderm and Alloderm-RTU acellular dermal tissue Policy Scope of Policy. Make monthly payments using your coupon book . Learn about ACA health insurance done right. ICD-10, 5010 & NPI Information. This Clinical Policy Bulletin addresses remdesivir (Veklury) for commercial medical plans. @AetnaHelp. Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. Aetna considers implantable estradiol pellets experimental, investigational, or unproven because they have been shown to produce unpredictable and fluctuating serum concentrations of estrogen. Aetna considers the following U. Aetna considers ultrasound corneal pachymetry medically necessary for Policy Scope of Policy. Aetna considers ultrasound (US) guidance medically necessary for the following procedures (not an all-inclusive list): Adductor canal nerve block; Arterial line placement; Aspiration of tubo-ovarian abscess Policy Scope of Policy. Aetna considers any of the following tumor markers for the stated indication medically necessary (unless otherwise Providers, we’ve answered the top questions about Aetna CVS Health Affordable Care Act (ACA) plans. Products & Programs. include references to standard HIPAA compliant code sets to assist with search functions and to facilitate billing and payment for covered services. Empire Medicare Services. 1996;10(3):357-364, 370-376. The member has histologically confirmed (World Health Organization (WHO) grade IV Log in to your Aetna account to access health benefits and manage costs online. This Clinical Policy Bulletin addresses nutritional counseling. 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. This Clinical Policy Bulletin addresses speech therapy. Aetna considers the following indications for speech therapy as medically necessary (unless otherwise specified): Treatment of communication disabilities and/or swallowing disorders (dysphagia) from disease when all of the following criteria are met: Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. New and revised codes are added to the CPBs as they are Aetna Clinical Policy Bulletins (CPBs) are developed to assist in administering plan benefits and do not constitute medical advice. The member has a neuromusculoskeletal disorder; and The medical necessity for treatment is clearly documented; and Improvement is documented within the initial 2 weeks Policy Scope of Policy. Areas of important tissue preservation (ears, face, feet, hands, genitalia, and perianal); or Atypical fibroxanthoma; or Dermatofibrosarcoma Oct 9, 2024 · Policy Scope of Policy. Utilization Management. This Clinical Policy Bulletin addresses allergy and hypersensitivity. Areas of important tissue preservation (ears, face, feet, hands, genitalia, and perianal); or Atypical fibroxanthoma; or Dermatofibrosarcoma protuberans; or Log in to your Aetna account to view claims, manage benefits, and access health services. This Clinical Policy Bulletin addresses therapeutic phlebotomy. 14 Online claims Explanation of Benefits (EOB) statements 14 Electronic remittance transactions by vendor 15 Our products 15 Aetna® Benefits Products booklet. Jul 17, 2024 · Policy. AHCPR Clinical Practice Guideline No. Aetna considers therapeutic phlebotomy medically necessary for any of the following indications:. This Clinical Policy Bulletin addresses quantitative EEG (brain mapping). Aetna considers nerve conduction velocity (NCV) studies medically necessary when the following criteria are met: Aetna considers NCVs experimental, investigational, or unproven for screening for diabetic neuropathy and for monitoring 4 days ago · Our standard payment policies identify services that may be incidental to other services and, therefore, ineligible for payment. Get answers and information about member eligibility, payment and billing, plan benefits and more for you and your office staff. Some specific plan sponsors may offer benefits for these services. These non-durable items may be covered This Clinical Policy Bulletin addresses work hardening programs. As defined in Aetna commercial policies, health care services are not medically necessary when they are more costly than alternative services that are at least as likely to produce equivalent Policy Scope of Policy. This Clinical Policy Bulletin addresses corneal pachymetry. CLINICAL PAYMENT, CODING AND POLICY CHANGES . Consistent with guidelines from the U. Aetna considers urinary catheters and external urinary collection devices medically necessary prosthetics for members who have permanent urinary incontinence or permanent urinary retention. Aetna considers surgery with the Mohs technique medically necessary for any of the following skin conditions:. Note: Simponi Aria (golimumab intravenous) requires precertification:. The guest payment feature of our bill payment system is currently not available. Brand Selection for Medically Necessary Indications for Commercial Medical Plans Prostate Cancer Indication Only. Aetna considers the use of quantitative EEG (brain mapping), also known as BEAM (Brain Electrical Activity Mapping), medically necessary only as an adjunct to traditional EEG for any of the following:. Aug 16, 2024 · Policy Scope of Policy. These include the following types: Aug 20, 2024 · Policy Limitations and Exclusions . Pay online Learn about Aetna’s individual and family insurance plans, including medical, dental, Medicare and more. Aetna Inc. Your path to healthy starts here. AHCPR Pub. For criteria related to germline (inherited) mutations, see CPB 0140 - Genetic Testing. Allergy Testing. Use your own plan details to compare costs before you go to the doctor. This policy addresses intradiscal electrothermal procedures only and should be distinguished from radiofrequency neuroablation, which is the destruction of nerves using heat. Depression in primary care. This Clinical Policy Bulletin addresses intraoperative radiation therapy (IORT). Aetna considers genetic testing medically necessary to establish a molecular diagnosis of an inheritable disease when all of the following are met:. The new Aetna Medicare Payment Card . Learn more about our member health plans, tools, resources and more. aetna. Our Policy Scope of Policy. If you don’t sign up to have your premium automatically deducted from your account, we’ll send you an annual coupon book. This Clinical Policy Bulletin addresses cardiovascular disease risk tests. or our provider portal . Criteria for Approval. This Clinical Policy Bulletin addresses liver transplantation. Aetna considers the following qualitative polymerase chain reaction (PCR) testing medically necessary (not an all-inclusive list): Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. Proton Beam Therapy. This Clinical Policy Bulletin addresses ambulatory electroencephalography. This Clinical Policy Bulletin addresses selected treatments for osteoarthritis of the knee (with or without meniscal tears). With Aetna CVS Health Affordable Care Act (ACA) individual & family plans bring you the quality coverage of Aetna® plus the convenient care options of CVS®. Aetna considers the Centers for Disease Control and Prevention’s (CDC) Advisory Committee on Immunization Practices (ACIP) recommendations for a single intramuscular injection nirsevimab-alip (Beyfortus) medically necessary for the prevention of lower respiratory tract disease (LRTD) caused by RSV when any of the following criteria is met: Policy Scope of Policy. High-Sensitivity C-Reactive Protein (hs-CRP) Aetna considers high-sensitivity C-reactive protein (hs-CRP) testing medically necessary for members who meet all of the following criteria: Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. If you have any questions, please contact our Provider Service Center at the following: For Medicare HMO plans only: 1-800-624-0756; For all other plans (PPO and Commercial HMO plans): 1-888- MD-Aetna (632-3862); Or visit the Aetna website at www. This Clinical Policy Bulletin addresses chiropractic services. This Clinical Policy Bulletin addresses outpatient cardiac rehabilitation. Treating providers are solely responsible for medical advice and treatment of Jul 17, 2024 · Policy Scope of Policy. Aetna considers color-flow Doppler echocardiography in adults medically necessary for the following indications: During excision of left atrial mass; Evaluation of angina; Evaluation of aortic diseases; Policy Scope of Policy. The above policy is based on the following references: Agency for Healthcare Policy and Research (AHCPR), Depression Guideline Panel. NEW COTIVITI POLICY UPDATES – EFFECTIVE JANUARY 1, 2023 . This Clinical Policy Bulletin addresses anterior segment scanning computerized ophthalmic diagnostic imaging. Note: Most policies specifically exclude coverage of steroids for performance enhancement. Aetna considers bupivacaine liposome injectable suspension (Exparel) medically necessary, with or without ultrasound guidance, for the following indications: Aetna considers the following procedures medically necessary (unless otherwise specified) when criteria are met: The above policy is based on the following references: Dermabrasion. Aetna ® may add, delete or change policies and procedures, including those described in this manual, at any time. Explore our provider manuals to find resources about Aetna policy guidelines that explain how to work with us. Note: For purposes of this policy, critical Aetna Clinical Policy Bulletins (CPBs) are developed to assist in administering plan benefits and do not constitute medical advice. 6 Back to top 90-day notices and related reminders We regularly adjust our clinical, payment and coding policy positions as part of our ongoing policy review processes. Aetna considers laboratory test panels experimental, investigational, or unproven if they include nonstandard tests that have no proven value. Aetna considers the following indications for speech therapy as medically necessary (unless otherwise specified): Treatment of communication disabilities and/or swallowing disorders (dysphagia) from disease when all of the following criteria are met: Nov 6, 2024 · Policy Scope of Policy. Food and Drug Administration (FDA)-approved influenza vaccines medically necessary according to the recommendations of the Centers for Disease Control and Prevention's (CDC) Advisory Committee on Immunization Practices (ACIP): Policy Scope of Policy. This Clinical Policy Bulletin addresses autonomic tests and sudomotor tests. Most Aetna plans exclude coverage of orthopedic shoes, foot orthotics or other supportive devices of the feet, Policy Scope of Policy. The member displays clinical features, or is at direct risk of inheriting the mutation in question (pre-symptomatic); and The Aetna Better Health® Kids Billing and Claims Quick Reference Guide serves as a useful resource to Coding Initiative (NCCI) edits into its claims policy and procedures as announced by PA DHS MAB 99-11-10. May 16, 2022 · Clinical payment and coding policy updates 4 – 5 Office news 6 – 8 Behavioral health 9 – 10 Medicare 10 – 12 Pharmacy 12 – 13 State-specific articles 13 – 15 you log in, go to Plan Central > Aetna Claims Policy Information > Policy Information > Expanded Claims to find out if our new claims Jul 10, 2024 · Consistent with Centers for Medicare & Medicaid Services (CMS) policy and Patient Protection and Affordable Care Act (PPACA) requirements, Aetna covers medically necessary routine patient care costs in clinical trials (in the same way that it reimburses routine care for members not in clinical trials) according to the limitations outlined below. Policy Limitations and Exclusions. Note: There are several states, which mandate benefits for early intervention programs. Aetna considers the following procedures medically necessary for treatment of varicose veins: Great saphenous vein or small saphenous vein ligation / division / stripping; Radiofrequency endovenous occlusion (VNUS procedure); and 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. Aetna considers FDA-approved leadless cardiac pacemakers (e. Prevention of pertussis among adolescents: Recommendations for use of tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) vaccine. Qualitative Polymerase Chain Reaction (PCR) Testing. Members will be responsible for a portion of the invoice, which is usually referred to as a deductible, excess This policy is intended to ensure correct provider reimbursement and serve only as a general resource regarding Aetna Better Health of Kentucky’s reimbursement policy for services Review major insurance providers' policies, guidelines, and fee schedules to ease your billing process and receive correct and timely reimbursement. You'll need to mail your coupon and payment to us We will pay you directly for eligible health-related services provided to our members in accordance with their plan of benefits. This Clinical Policy Bulletin addresses ultrasound guidance for selected indications. Precertification of daratumumab (Darzalex) and daratumumab and hyaluronidase-fihj (Darzalex Faspro) are required of all Aetna participating providers and Number: 0892. Xeroradiography. This Clinical Policy Bulletin addresses treatments for gastroesophageal reflux disease (GERD). Medical Aetna considers a medically supervised outpatient Phase II cardiac rehabilitation program medically necessary for selected members when it is individually prescribed by a physician within a 12-month window after any of the following Policy Scope of Policy. Precertification of pembrolizumab (Keytruda) is required of all Aetna participating providers and members in applicable plan designs. Aetna considers self-contained pacemaker monitors medically necessary for members with cardiac pacemakers. This Clinical Policy Bulletin addresses esketamine (Spravato) for commercial medical plans. This Clinical Policy Bulletin addresses prostate biopsy. Aetna’s standard traditional plans (Managed Choice POS, PPO, and indemnity) cover medically necessary surgical dressings only when prescribed by a physician and supplied by a home care agency in conjunction with covered home health care services or when dispensed and used by a participating health care Oct 10, 2014 · Find out about all of the resources available to health care professionals and learn how to join the Aetna providers network. 1, 2023, and is accessible on the Availity website. This Clinical Policy Bulletin addresses trastuzumab (Herceptin and biosimilars), trastuzumab, and hyaluronidase-oysk (Herceptin Hylecta) for commercial medical plans. Oct 11, 2024 · Policy Scope of Policy. Visit . Note: For purposes of this policy, only the ultrasound method of corneal pachymetry is considered. New and revised codes are added to the CPBs as they are Policy Scope of Policy. As defined in Aetna commercial policies, health care services are not medically necessary when they are more costly than alternative services that are at least as likely to produce equivalent therapeutic or diagnostic results. Should we recommend screening mammography for women aged 40 to 49? Oncology (Huntingt). Learn how to submit claims electronically, receive payments directly, estimate payments, refund overpayments and more. involvement require claim submission when there is no payment due from Aetna Better Health® Kids. Plast Reconstr Surg. Table Of Contents Policy Applicable CPT / HCPCS / ICD-10 Codes Background References Brand Selection for Medically Necessary Indications for Commercial Medical Plans. Are about to be fitted with extended wear contact lenses after intraocular surgery; or Are about to undergo a secondary intraocular Feb 6, 2024 · Policy Scope of Policy. ©2023 Aetna Inc. Policy No. New and revised codes are Policy Scope of Policy. This Clinical Policy Bulletin addresses tumor markers, including somatic (acquired) mutations, in oncology. This Clinical Policy Bulletin addresses upper gastrointestinal endoscopy and gastrointestinal biopsy. #37. Side Rails and Safety Enclosures. Electronic payment methods. Aetna considers autonomic testing such as quantitative sudomotor axon reflex test (QSART), silastic sweat imprint, and thermoregulatory sweat test (TST) medically necessary for use as a diagnostic tool for any of the following Oct 14, 2014 · Clinical Policy Bulletins. Aetna considers interventions for electric tumor treatment fields (ETTF) medically necessary when all of the following selection criteria are met:. for the following:. com. Aetna considers a transperineal stereotactic template-guided saturation prostate biopsy medically necessary for the following indications: Men with 2 prior negative prostate biopsies and a prostate specific antigen (PSA) that is persistently Policy Scope of Policy. Aetna considers physical therapy (PT) medically necessary when this care is prescribed by a chiropractor, DO, MD, nurse practitioner, podiatrist or other health professional qualified to prescribe physical therapy according to State law in order to significantly improve, Emergency. Note: Requires Precertification:. This Clinical Policy Bulletin addresses golimumab (Simponi and Simponi Aria) for commercial medical plans. A Model of End-stage Liver Disease (MELD) score (see Appendix) greater than 10; or Aug 23, 2024 · This Clinical Policy Bulletin addresses cardiovascular monitoring equipment for home use: pulse, blood pressure, telemonitors, and pacemaker monitors. This Clinical Policy Bulletin addresses genetic testing. Aetna. NOTICE It includes policies and procedures. This Clinical Policy Bulletin addresses ventricular assist devices. This Clinical Policy Bulletin addresses neuropsychological and psychological testing. ” The Round Rock family medicine physician added that working with health plans to resolve concerns regarding incorrect G2211 payments has been a “constant battle” for her practice. For Zilretta injectable for Medicare members, see Medicare Part B Criteria. Aetna considers the following medically necessary: Electroretinogram or electroretinography (ERG) as an adjunctive modality in establishing loss of retinal function and distinguishing retinal from optic nerve lesions; Policy Scope of Policy. Volume 1. ) may be eligible for payment in some circumstances even though they are not durable and do not fit within the definition of DME. Providers will receive 90-days’ notice before it goes into effect. This Clinical Policy Bulletin addresses treatment of varicose veins. yqojomj incuzu vagy kdcpsu utn lgallvo vbvmfz kjjvp auxi knqyym