Aetna considers the following outpatient medical self-care programs medically necessary (subject to applicable plan coverage definitions and limitations; please check benefit plan descriptions for details):

• Back school for members with chronic back pain who meet criteria in CPB 0232 - Back Pain - Non Invasive Treatments;
• Cardiac rehabilitation for members with cardiac disease who meet criteria in CPB 0021 - Cardiac Rehabilitation;
• Diabetes education programs for members with diabetes who meet criteria in CPB 0070 - Diabetes Tests, Programs and Supplies;

• Pulmonary rehabilitation for members with chronic pulmonary diseases who meet criteria in CPB 0032 - Pulmonary Rehabilitation.

Note on Recognized Programs:

Consideration of coverage will be extended to other medically necessary self-care programs (subject to plan coverage definitions and limitations; please check benefit plan descriptions) when:

• The program consists of services provided by recognized health care professionals (e.g., doctors, registered nurses, social workers, physical therapists, dietitians**, respiratory therapists**, etc.); and
• The program is coordinated with Aetna's Patient Management Department (in Aetna network plans); and
• The program is designed to educate the member about specific conditions and lifestyle changes necessary as a result of the medical condition; and
• The program is directed and supervised by a physician; and

• The program is prescribed by the attending physician for a member with a medical condition amenable to self-care (e.g., diabetes, chronic back pain, chronic pulmonary disease or cardiac disease).

Frequency and Duration:

The medically necessary frequency and duration of self-care programs varies depending on the goals and objectives of the program.

Aetna considers participation in a self-care program for a particular illness medically necessary once per lifetime unless an additional episode of illness requires another self-care program (e.g., second heart attack).

Note on Non-Covered Programs:

Coverage is not extended for self-care programs that:

• Are available to the general public without charge; or
• Are general health or lifestyle education programs -- not related to the member's diagnosis or condition; or

• Consist of services not generally accepted as necessary and appropriate for management of the disease or injury.

**Note on Services Provided by Dietitians and Respiratory Therapists:

Self-care programs offering services provided by dietitians and respiratory therapists may be covered when required by law or when all of the following criteria are met:

• The charges are billed by their doctor or hospital employer; and
• The services are covered under the policy; and
• They are employed by and working under the supervision of a hospital or recognized health care facility, a home health care agency or a qualified doctor; and

• They are licensed, certified or qualified by professional credentials or degree to provide the services.

Note on Work Hardening Programs (see CPB 0198 - Work Hardening Programs):

Work hardening programs are not considered covered outpatient self-care programs under Aetna medical plans.  The primary goal of these programs is return to work, not treatment of a disease or injury.  Their purpose is training the individual to work with their current limitations and to be able to function with maximum productivity in their job.  This is a form of vocational rehabilitation rather than a covered outpatient self-care program.

See also CPB 0342 - Intestinal Rehabilitation Programs.

Outpatient medical self-care programs refer to programs that focus on self-care activities for management of disease.  Self-care programs follow evidence based guidelines, and may refer to diet, exercise, administration of medications, monitoring disease, avoiding activities that exacerbate disease, and obtaining recommended follow-up medical care.  Another important part of self-care is being able to recognize the need for medical care.