Aetna Clinical Policy Bulletins (CPBs) are integral to the administration of healthcare plan benefits. It is crucial to understand that these CPBs are designed to assist in this administrative process and should not be interpreted as medical advice. The responsibility for medical advice and treatment rests solely with the treating healthcare providers. For any concerns or questions related to a CPB and its impact on coverage or health condition, it is essential to consult with your healthcare provider.
While CPBs serve to facilitate benefit administration, they are not a comprehensive description of plan benefits themselves. Instead, Aetna CPBs articulate Aetna’s stance on the medical necessity, experimental, investigational, unproven, or cosmetic nature of specific healthcare services or supplies. These determinations are grounded in a thorough review of current clinical evidence. This evidence base includes clinical outcome studies published in peer-reviewed medical literature, the regulatory status of relevant technologies, evidence-based guidelines from public health and health research bodies, and the positions of leading national health professional organizations. Aetna also considers the insights of physicians practicing in relevant clinical areas and other pertinent factors to ensure a balanced and informed perspective.
Aetna assumes no liability for the content of external sources referenced within CPBs. The analyses, discussions, conclusions, and positions presented in CPBs, including any mentions of specific providers, products, processes, or services by name or manufacturer, represent Aetna’s professional opinion. These are provided without any intention to defame. Aetna retains the right to modify these conclusions as clinical information evolves and welcomes additional relevant information, including corrections of any factual inaccuracies. This commitment to accuracy and updates is part of providing a responsible and reliable framework for healthcare decisions, contributing to a more Compassionate Care Program experience by ensuring policies are up-to-date and reflective of the latest medical understanding.
For search functionality and to streamline billing and payment for covered services, CPBs incorporate standard HIPAA compliant code sets. As new codes are introduced or existing ones revised, CPBs are updated accordingly. When submitting bills, it is imperative to use the most appropriate code that is effective on the date of submission. The use of unspecified, nonspecific, or unlisted codes should be avoided to maintain clarity and accuracy in billing processes. This attention to detail in coding directly supports efficient administration, which is a behind-the-scenes element of a compassionate care program, ensuring that administrative hurdles are minimized for both providers and patients.
It is important to recognize that each benefit plan has its own defined scope of covered services, exclusions, and potential limitations such as dollar caps. Members and healthcare providers must consult the member’s specific benefit plan documentation to ascertain whether any exclusions or limitations apply to a particular service or supply. While a CPB may determine a service or supply to be medically necessary, this does not automatically guarantee coverage under a member’s plan. Coverage is ultimately determined by the specifics of the member’s benefit plan. It is possible for some plans to exclude coverage for services or supplies that Aetna deems medically necessary. In cases of conflict between a CPB and a member’s benefit plan, the benefit plan document will take precedence. Understanding this distinction is key to navigating healthcare coverage and ensuring access to necessary care within the boundaries of a given plan, a critical component of any truly compassionate care program.
Furthermore, coverage mandates may arise from applicable legal requirements at the state, federal, or CMS (for Medicare and Medicaid members) level. For detailed information, refer to the CMS’s Medicare Coverage Center. These external mandates add another layer to the coverage landscape, highlighting the complexity of healthcare administration and the necessity for clear, accessible policies like CPBs to guide decision-making within a compassionate care program.
CPBs are regularly updated and are subject to revisions as medical knowledge and practices evolve. Given their technical nature and intended use by Aetna’s professional staff for clinical determinations related to coverage decisions, members are encouraged to review these bulletins in consultation with their healthcare providers. This collaborative approach ensures that patients can fully understand the policies that may affect their care. In situations where a physician has questions or wishes to discuss a medical necessity precertification determination made by Aetna’s medical director based on a CPB, a peer-to-peer review process is available. This process allows for direct dialogue and further clarification, reinforcing the commitment to fair and considered decisions within the compassionate care program.
While CPBs define Aetna’s clinical policy guidelines, medical necessity determinations for coverage decisions are made on a case-by-case basis. If a member disagrees with a coverage decision, Aetna provides a formal appeal process. Additionally, members may have the option for an independent external review of coverage denials based on medical necessity or experimental/investigational status, particularly when the member’s financial responsibility is $500 or more. However, it’s important to note that applicable state mandates will supersede these processes for fully insured plans and self-funded non-ERISA plans (such as government, school boards, or church plans). For more information on this, please see Aetna’s External Review Program. These appeal and review mechanisms are essential safeguards in a compassionate care program, ensuring fairness and due process in coverage decisions.
The five-character codes included in Aetna CPBs are derived from Current Procedural Terminology (CPT®), copyrighted by the American Medical Association (AMA). CPT is a system developed by the AMA that uses descriptive terms and five-character codes for reporting medical services and procedures performed by physicians. Aetna is responsible for the content of its CPBs, and no endorsement by the AMA is intended or implied. The AMA disclaims any responsibility for consequences or liabilities arising from the use, non-use, or interpretation of information within Aetna CPBs. CPT does not include fee schedules, basic unit values, relative value guides, conversion factors, or scales. Any use of CPT outside of Aetna CPBs should refer to the most current edition of Current Procedural Terminology for the complete and updated listing of CPT codes and terms. Applicable FARS/DFARS regulations apply.
LICENSE FOR USE OF CURRENT PROCEDURAL TERMINOLOGY, FOURTH EDITION (“CPT®”)
CPT copyright 2015 American Medical Association. All Rights Reserved. CPT is a registered trademark of the American Medical Association.
Users are authorized to utilize CPT as incorporated in Aetna CPBs solely for personal use within healthcare programs administered by Aetna. The AMA retains all copyright, trademark, and other rights to CPT.
Unauthorized uses are prohibited, including but not limited to: resale or licensing of CPT copies, transferring copies to unauthorized parties, creating derivative works of CPT, or any commercial use of CPT. For uses not authorized, a license must be obtained directly from the American Medical Association, CPT Intellectual Property Services, 515 N. State Street, Chicago, Illinois 60610. Applications are available on the AMA website: American Medical Association Web site.
U.S. Government Rights
CPT is considered commercial technical data, computer databases, computer software, and software documentation, developed at private expense by the American Medical Association. U.S. Government rights regarding use, modification, reproduction, release, performance, display, or disclosure are subject to restrictions as per DFARS 252.227-7015(b)(2) (June 1995) and/or DFARS 227.7202-1(a) (June 1995) and DFARS 227.7202-3(a) (June 1995) for Department of Defense procurements, and FAR 52.227-14 (June 1987) and/or FAR 52.227-14 (June 1987) and FAR 52.227-19 (June 1987) for non-Department of Defense Federal procurements, along with any applicable agency FAR Supplements.
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CPT is provided “as is” without warranties, either expressed or implied, including merchantability and fitness for a particular purpose. CPT does not include fee schedules, unit values, or related listings. The AMA does not practice medicine or dispense medical services. Aetna, Inc. is responsible for the content of this product, and AMA endorsement is not intended or implied. The AMA disclaims liability for any consequences related to the use, non-use, or interpretation of information within this product.
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This information is not an offer of coverage or medical advice; it is a general description of plan benefits and not a contract. In case of conflict with plan documents, the plan documents govern. This comprehensive overview of Aetna’s Clinical Policy Bulletins is provided to enhance understanding and transparency, key pillars in delivering a compassionate care program.
