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Determining Coverage

Utilization management: Guidelines for determining coverage

 


First, our staff collects information about a member's clinical condition. 

Then, our staff uses evidence-based clinical guidelines from nationally recognized authorities  to guide utilization management decisions involving precertification, concurrent review, and retrospective review.

Aetna staff use the following criteria as guides in making coverage determinations as applicable:

Vendors used 
In some states, Aetna delegates utilization review of certain services including radiology and physical/occupational therapy, to outside vendors. Refer to the following vendor websites for a description or copy of the applicable clinical criteria: