Last Review: This is the date of the latest version of this policy.

Effective: This is the date of the original version of this policy.

Next Review: This is the anticipated date* of the next review of this policy.

Updated: Dates the CPB was reviewed and policy was maintained with no change. Changes may have been made to other sections of the CPB.

Revised: Dates of changes to the policy section of the CPB. Changes also may have been made to other sections of the CPB.

* This date is subject to change based on various factors, including but not limited to intervening clinical developments and available resources. Aetna does not hereby commit to review any specific CPB by a specific date, and expressly reserves the right to change any CPB without notice. Aetna does not hereby assume any obligation to update information presented in this document, so information contained herein may be out of date at any given time.