Utilization Management
How we determine coverage
Guidelines for coverage determination
Coverage determination is based on recognized guidelines or criteria that include:
- Aetna’s Clinical Policy Bulletins
- Centers for Medicare & Medicaid Services National Coverage Determinations, Local Coverage Determinations And Medicare Benefit Policy Manual
- MCG™ guidelines
- American Society of Addiction Medicine Placement Criteria for the Treatment of Substance-Related Disorders, Second Edition, Revised (ASAM PPC-2R)
- Applied Behavioral Analysis (ABA) Medical Necessity Guidelines© for the Treatment of Autism Spectrum Disorders
- Level of Care Assessment Tool (LOCAT)
Learn more about LOCAT and ABA
Medicare Notice of Coverage Determinations
Outside Vendors
In some states, we delegate utilization review of certain services, including radiology and physical/occupational therapy, to vendors.
Concurrent review
Sometimes utilization management takes place during inpatient care or outpatient treatment.
Retrospective review
In a retrospective review, coverage is determined after treatment has occurred.
Note: More stringent state requirements may supersede the requirements of this policy.
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