Aetna Clinical Policy Bulletins (CPBs) are designed to help manage your plan benefits effectively. It’s important to understand that these bulletins are not medical advice. Your healthcare providers are solely responsible for your medical care and treatment. If you have any questions regarding a CPB and how it relates to your coverage or health condition, please discuss it with your treating provider.
While CPBs assist in the administration of plan benefits, they are not a complete description of your benefits. Instead, CPBs represent Aetna’s assessment of whether specific medical services or supplies are considered medically necessary, experimental, investigational, unproven, or cosmetic. These determinations are based on a thorough review of current clinical information. This includes clinical outcome studies published in peer-reviewed medical literature, the regulatory status of technologies, evidence-based guidelines from public health and health research agencies, guidelines and positions from leading national health professional organizations, insights from practicing physicians in relevant fields, and other pertinent factors.
Aetna is not responsible for the content of any external sources cited or referenced within the CPBs. The discussions, analyses, conclusions, and positions presented in the CPBs, including any mention of a specific provider, product, process, or service by name or trademark, reflect Aetna’s opinion and are not intended to be defamatory in any way. Aetna retains the right to update these conclusions as clinical information evolves and welcomes relevant information, including corrections of any factual errors.
To aid in search functionality and streamline billing and payment for covered services, CPBs incorporate references to standard HIPAA compliant code sets. CPBs are updated with new and revised codes regularly. When submitting bills, it’s crucial to use the most accurate code effective at the time of submission. It’s best to avoid using unlisted, unspecified, and nonspecific codes.
Each Aetna benefit plan outlines which services are covered, which are excluded, and any applicable dollar limits or other restrictions. As a card member, you and your providers must consult your specific benefit plan to determine if any exclusions or limitations apply to a particular service or supply. Just because a CPB concludes that a service or supply is medically necessary, this does not guarantee coverage (payment by Aetna) for every member. Your individual benefit plan is the ultimate determinant of coverage. Some plans may not cover services or supplies that Aetna deems medically necessary. In situations where there’s a conflict between a CPB and your benefit plan, the terms of your benefit plan will take precedence.
Furthermore, coverage can be mandated by state, federal, or CMS legal requirements, especially for Medicare and Medicaid members.
See CMS’s Medicare Coverage Center
It’s important to note that Clinical Policy Bulletins are updated frequently and are subject to change.
Given the technical nature of CPBs, which are primarily designed for professional staff involved in coverage decisions, members should review these bulletins with their healthcare providers. This ensures you fully understand Aetna’s policies as they relate to your care. If your physician has questions or wishes to discuss a medical necessity precertification decision made by our medical director based on a CPB, they can request a peer-to-peer review.
While CPBs establish Aetna’s clinical policy, medical necessity determinations for coverage decisions are made on a case-by-case basis. If you, as a card member, disagree with a coverage decision, Aetna provides a formal appeal process. Additionally, you may have the option for an independent external review of coverage denials based on medical necessity or experimental/investigational status, particularly when the financial responsibility is $500 or more. However, state mandates may override these processes for fully insured plans and self-funded non-ERISA plans (like government, school boards, or church plans).
See Aetna’s External Review Program
The five-character codes within Aetna CPBs are sourced from Current Procedural Terminology (CPT®), copyrighted by the American Medical Association (AMA). CPT is a system developed by the AMA that lists descriptive terms, five-character codes, and modifiers used 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 should be inferred. The AMA disclaims any liability for consequences related to the use, non-use, or interpretation of information within Aetna CPBs. CPT does not include any fee schedules, basic unit values, relative value guides, conversion factors, or scales. For any use of CPT outside of Aetna CPBs, 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.
As an Aetna card member or affiliated party, you are authorized to use CPT as it appears in Aetna CPBs solely for your personal use in connection with healthcare programs managed by Aetna, Inc. You acknowledge that the AMA owns all copyright, trademark, and other rights to CPT.
Any use not specifically authorized is prohibited. This includes, but is not limited to, making copies of CPT for resale or licensing, transferring CPT copies to unauthorized parties, creating modified works from CPT, or any commercial exploitation of CPT. To obtain a license for any unauthorized use, you must contact the American Medical Association, CPT Intellectual Property Services, 515 N. State Street, Chicago, Illinois 60610. Application details are available on the AMA website: www.ama-assn.org/go/cpt.
Go to the American Medical Association Web site
U.S. Government Rights
This product incorporates CPT, considered commercial technical data, computer databases, computer software, and software documentation, developed privately by the American Medical Association, 515 North State Street, Chicago, Illinois, 60610. U.S. Government rights regarding the use, modification, reproduction, release, performance, display, or disclosure of this technical data, computer databases, computer software, and software documentation are governed by the limited rights restrictions of 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 U.S. Department of Defense procurements. For non-Department of Defense Federal procurements, the relevant restrictions are the limited rights restrictions of FAR 52.227-14 (June 1987) and/or the restricted rights provisions of FAR 52.227-14 (June 1987) and FAR 52.227-19 (June 1987), along with any applicable agency FAR Supplements.
Disclaimer of Warranties and Liabilities.
CPT is provided “as is” without any warranties, either express or implied, including but not limited to warranties of merchantability and fitness for a particular purpose. CPT does not include fee schedules, basic unit values, relative values, or related listings. The American Medical Association (AMA) does not practice medicine or provide medical services directly or indirectly. Aetna, Inc. is responsible for the content of this product, and no AMA endorsement is intended or implied. The AMA disclaims responsibility for any consequences or liabilities arising from the use, non-use, or interpretation of information within this product.
This Agreement will terminate immediately if you breach its terms. The AMA is a third-party beneficiary to this Agreement.
By proceeding, you acknowledge that you have read, understood, and agree to these terms and conditions.
Important Notice for Arizona Residents:
The information on this website and the products described may not accurately reflect product design or availability in Arizona. Residents, members, employers, and brokers in Arizona should contact Aetna directly or their employers for specific details about Aetna products and services in Arizona.
This information is not an offer of coverage or medical advice. It provides a general overview of plan or program benefits and should not be considered a contract. In the event of any discrepancy between this information and your plan documents, the plan documents will be the governing authority.
