Aetna Clinical Policy Bulletins (CPBs) are essential documents designed to assist in the administration of healthcare plan benefits. It’s crucial to understand that these bulletins are not intended as medical advice. The responsibility for medical advice and treatment rests solely with healthcare providers. If you are an Aetna member, it’s important to discuss any CPB related to your health condition or coverage with your treating physician.
While CPBs are tools to help manage plan benefits, they do not represent a complete description of your benefits package. Instead, Aetna CPBs outline the company’s stance on whether specific medical services or supplies are considered medically necessary, experimental, investigational, unproven, or cosmetic. These determinations are made after a thorough review of current clinical evidence. This evidence includes clinical outcome studies published in peer-reviewed medical literature, the regulatory status of medical technologies, evidence-based guidelines from public health and health research organizations, positions of leading national health professional bodies, insights from practicing physicians in relevant fields, and other pertinent factors.
Aetna explicitly states that it makes no endorsements and assumes no liability regarding the content of any external sources cited or referenced within the CPBs. The analyses, discussions, conclusions, and positions presented in CPBs, including any mention of a specific provider, product, process, or service by name, trademark, or manufacturer, reflect Aetna’s opinion and are not intended to be defamatory in any way. Aetna retains the explicit right to revise these conclusions as new clinical information becomes available and welcomes relevant information, including corrections of any factual inaccuracies.
To enhance search functionality and streamline billing and payment processes for covered services, CPBs incorporate references to standard HIPAA compliant code sets. As codes are updated or revised, they are added to the CPBs. It is imperative to use the most appropriate and current code when billing, effective from the date of submission. The use of unlisted, unspecified, and nonspecific codes should be avoided.
Each Aetna benefit plan has its own defined scope of coverage, outlining which services are covered, which are excluded, and any applicable dollar limits or restrictions. Members and their healthcare providers must consult the member’s specific benefit plan documents to ascertain any exclusions or limitations relevant to a particular service or supply. It’s important to note that a determination of medical necessity in a CPB does not automatically guarantee coverage (i.e., payment by Aetna) for a specific member. Coverage is ultimately determined by the member’s benefit plan. Some plans may not cover services or supplies that Aetna deems medically necessary. In cases of discrepancy between a CPB and a member’s benefit plan, the terms of the benefit plan will take precedence.
Furthermore, coverage mandates may be imposed by applicable legal requirements at the state or federal level, or by CMS for Medicare and Medicaid beneficiaries.
See CMS’s Medicare Coverage Center
It is crucial to be aware that Aetna Clinical Policy Bulletins are updated regularly and are subject to change over time.
Given the technical nature of CPBs, which are primarily designed for use by Aetna’s professional staff in making clinical coverage decisions, members are encouraged to review these bulletins with their healthcare providers. This ensures a comprehensive understanding of Aetna’s policies. If a physician has questions or wishes to discuss a medical necessity precertification decision made by Aetna’s medical director based on a CPB, they may request a peer-to-peer review.
While CPBs establish Aetna’s clinical policy guidelines, medical necessity determinations for coverage decisions are made on an individual, case-by-case basis. Aetna provides a formal appeal process for members who disagree with a coverage decision. Additionally, members might be eligible for an independent external review of coverage denials based on medical necessity or experimental/investigational status, particularly when the member’s financial responsibility for the service or supply in question is $500 or greater. However, state mandates will supersede these provisions for fully insured plans and self-funded non-ERISA plans (such as government, school boards, or church plans).
See Aetna’s External Review Program
The five-character codes included in Aetna CPBs are sourced from Current Procedural Terminology (CPT®), copyrighted by the American Medical Association (AMA). CPT, developed by the AMA, is a system of descriptive terms, five-character identifying codes, and modifiers used for reporting medical services and procedures performed by physicians.
The content of Aetna CPBs is the responsibility of Aetna, and no endorsement by the AMA is intended or should be inferred. The AMA disclaims any responsibility for consequences or liability 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 reference the most current edition of Current Procedural Terminology, which contains the complete and up-to-date listing of CPT codes and descriptive 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.
Authorization is granted to you, your employees, and agents to use CPT solely as incorporated within Aetna CPBs for your personal use in direct participation in healthcare programs managed by Aetna, Inc. You acknowledge the AMA’s ownership of all copyright, trademark, and other rights in CPT.
Any use not expressly authorized is prohibited, including but not limited to making copies of CPT for resale or licensing, transferring CPT copies to parties not bound by this agreement, creating derivative works of CPT, or any commercial use of CPT. For any uses of CPT not authorized herein, 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 American Medical Association website: www.ama-assn.org/go/cpt.
Go to the American Medical Association Web site
U.S. Government Rights
This product includes CPT, which is considered commercial technical data, computer databases, commercial computer software, and commercial computer software documentation, as applicable. It was developed exclusively at private expense by the American Medical Association, 515 North State Street, Chicago, Illinois, 60610. U.S. Government rights concerning the use, modification, reproduction, release, performance, display, or disclosure of this technical data, computer databases, computer software, and computer software documentation are governed by the limited rights restrictions of DFARS 252.227-7015(b)(2) (June 1995) and/or 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. For non-Department of Defense Federal procurements, the applicable regulations 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 relevant 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 implied 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 engage in the practice of medicine or the dispensing of medical services, either directly or indirectly. Aetna, Inc. is responsible for the content of this product, and no AMA endorsement is intended or implied. The AMA disclaims any responsibility for consequences or liability attributable to or related to any use, non-use, or interpretation of information contained or not contained within this product.
This Agreement will terminate immediately upon notice if you violate its terms. The AMA is a third-party beneficiary to this Agreement.
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Please note that the information on this website and the products described may not reflect product design or availability in Arizona. Residents of Arizona, including members, employers, and brokers, should contact Aetna directly or their employers for specific information regarding Aetna products and services in Arizona.
This information is not an offer of coverage or medical advice. It serves as a partial, general description of plan or program benefits and should not be considered a contract. In the event of any conflict between your plan documents and this information, the provisions of your plan documents will govern.
