Aetna participating provider Precertification List*

Precertification: when is it required?

Search to find if a specific code needs precertification.  (PDF)

When using the code search, enter valid 5-digit codes. This tool also helps determine if a special program applies.

Applies to: Aetna Choice®, Aetna Choice® POS II, Aetna Medicare^SM Plan (PPO), Aetna Medicare^SM Plan (HMO), Aetna Medicare Dual Advantage^SM Plan (HMO), all Aetna HealthFund® products, Aetna Health Network Only^SM, Aetna Health Network Option^SM, Aetna Open Access® Elect Choice®, Aetna Open Access® HMO, Aetna Open Access® Managed Choice®, Open Access Aetna Select^SM, Elect Choice®, HMO, Managed Choice® POS, Open Choice®, Quality Point-of-Service® (QPOS®) and Aetna Select^SM benefits plans and all products that may include the Aexcel® networks and include the designation Aexcel or Aexcel Plus®**

Precertification  exceptions
Please see the Exceptions to Aetna Precert List box on the bottom of this page.

Aetna Behavioral Health precertification list  (PDF)

Precertification – Non-Participating Provider Request  (PDF)

Aetna Student Health  (PDF)

Precertification list*
Download/Print 2010 Precertification List  (PDF)

1. Inpatient confinements
   • Surgical and non-surgical
     • Including vaginal or Caesarean deliveries excluding routine delivery ***
   • Skilled nursing facility
   • Rehabilitation facility
   • Inpatient hospice (except Medicare)
     
2. Reconstructive or other procedures that may be considered cosmetic
   • Blepharoplasty/canthopexy/canthoplasty
   • Breast reconstruction/breast enlargement
   • Breast reduction/mammoplasty  
   • Cervicoplasty
   • Chemical Peels
   • Excision of excessive skin due to weight loss
   • Gastroplasty/gastric bypass
   • Hair transplant
   • Injection of filling material
   • Intersex Surgery
   • Lipectomy or excess fat removal  
   • Otoplasty
   • Pectus excavatum repair
   • Rhinoplasty/rhytidectomy
   • Surgical treatment of gynecomastia
   • Sclerotherapy or surgery for varicose veins
     
3. Artificial intervertebral disc surgery
   
4. Lumbar spinal fusion surgery
   
5. Uvulopalatopharyngoplasty, including laser-assisted procedures
   
6. Orthognathic surgery procedures, bone grafts, osteotomies and surgical management of the temporomandibular joint
   
7. Dental implants and oral appliances
   
8. Elective (non-emergent) transportation by ambulance or medical van, and all transfers via air ambulance
   
9. The following conditionally eligible services†
   • Alpha 1-proteinase inhibitor -- human
   • Autologous Chondrocyte Implantation, Carticel®
   • Botox injections -- botulinum toxin type A
   • Cochlear device and/or implantation
   • Cognitive skills development
   • Dorsal Column (lumbar) Neurostimulators: Trial or Implantation
   • GI tract imaging through capsule endoscopy
   • High-frequency chest wall oscillation generator system
   • Hyperbaric oxygen therapy
   • Onco Type DX
   • Osseointegrated implant
   • Osteochondral allograft/knee
   • Stereotactic radiosurgery
   • Somatosensory evoked potential studies
     
10.  Medical injectables
    • Blood-clotting factors
    • Growth hormone
    • Interferons when used for hepatitis C
      • Pegasys®
      • Peg Intron®
      • Rebetron®
      • Roferon A®
      • Intron A®
      • Infergen®
    • Intravenous immunoglobulin (IVIG)
    • For the following services, call 1-866-503-0857 or, fax applicable request forms to 1-888-267-3277
      • Acthar Gel®
      • Erbitux®
      • Erythropoesis Stimulating Agents (ESA), such as darbepoetin alpha (Aranesp®), epoetin alpha (Epogen® and Procrit®) and epoetin beta (Micera®)
      • Provenge®
      • Rituxan® when used for Rheumatoid Arthritis
      • Synagis®
      • Xolair®
      • Vectibix®
        
11.  All home health care services, including home uterine monitoring and home hospice
    
12.  Selected durable medical equipment
    • Electric or motorized wheelchairs and scooters
    • Limb prosthetics
    • Customized braces
      
13.  In-network level of benefits for nonparticipating physicians and providers for non-emergent services††, only when there is an identified network deficiency.  (This category does not apply to Open Choice members.)
    
14.   Nonparticipating free-standing ambulatory surgical facility services, when referred by a participating provider (Effective July 1, 2010).
15.  Dialysis visits
    • Call 1-866-503-0857 or fax applicable request forms to 1-888-267-3277
16.  Special programs
    • Beginning Right^® maternity program, including genetic testing, antenatal testing, perinatal consultations and counseling: 1-800-272-3531
    • BRCA genetic testing: 1-877-794-8720
    • Infertility Program: 1-800-575-5999
    • To precertify mental health or substance abuse services, see the member’s ID card.   
    • National Medical Excellence Program^®: 1-877-212-8811 for all major organ transplant evaluations and transplants including, but not limited to, kidney, liver, heart, lung and pancreas, and bone marrow replacement or stem cell transfer after high-dose chemotherapy
    • Pre-implantation genetic testing: 1-800-575-5999 
    • Pediatric Congenital Heart Surgery Program: see the member’s ID card to contact the Precertification unit
    • Connecticut:
      • For HMO and ACAS plan members: 
        • Outpatient physical and occupational therapy precertification through Orthonet at 1-800-771-3205
    • Metro NY/NNJ:
      • For HMO-based plan members only:
        • Outpatient physical and occupational therapy precertification through Orthonet at 1-800-771-3205
        • Radiation Oncology precertificaion through CareCore
          • 1-888-647-5940 for Northern New Jersey members
          • 1-888-622-7329 for NY members

    • Where applicable

      • For HMO-based plans and Medicare Advantage members in PA, SNJ, DE, MD, DC and VA only:
      • Sleep apnea study management moving from facility-based study to homebased study through MedSolutions National at 1-888-693-3211 prior to performing these tests. (Effective July 15, 2010)
    • Where applicable
      • For all members (with plans applicable to this precert list):
        • Outpatient imaging precertification for computed tomographic (CT) studies, coronary CT angiography, MRI/MRA, nuclear cardiology, nuclear medicine, PET scans and non-urgent outpatient diagnostic left heart catheterizations and echo stress tests through regional-specific Radiology Benefit Manager (MedSolutions or Care Core National)
      • For HMO-based plan members only:
        • Chiropractic therapy precertification through regional-specific managed service organizations (American Chiropractic Network, American Specialty Health, Healthways Wholehealth Network and Triad)

• Electronic submission of precert requests and inquiries is preferred. If you require assistance with precertification, please call our Aetna Voice Advantage^® line using the appropriate phone number indicated below and select the precertification option:
  • For HMO-based benefits plans, call 1-800-624-0756.
  • For indemnity and PPO-based benefits plans, call 1-888-632-3862.
• Visit Clinical Policy Bulletins and DocFind^®.
• Contact Aetna Pharmacy Management at 1-800-414-2386 for precertification of oral medications only.
• Call 1-866-782-2779 for information on injectable medications not listed.
• Precertification approvals are valid for six months in all states unless otherwise indicated at the time of precertification.

Precert Exceptions:
*  The term precertification here means the utilization review process to determine whether the requested service, procedure, prescription drug, or medical device meets the company's clinical criteria for coverage.  It does not mean precertification as defined by Texas law, as a reliable representation of payment of care or services to fully insured HMO and PPO members.

**  Not all plans are offered in all service areas.  Precertification is required when Aetna is secondary payer. 

***   A total length of stay of 3 days or less for vaginal deliveries, or a total length of stay of 5 days or less for a cesarean Section

†  All services deemed "never effective" are excluded from coverage.  Aetna defines a service as "never effective" when it is not recognized according to professional standards of safety and effectiveness in the United States for diagnosis, care or treatment.  Visit the secure website, available through www.aetna.com, for more information.  Select "Claims,” "CPT/HCPCS Coding Tool," "Clinical Policy Code Lookup."

††  All products that include Aetna HealthFund®, Aexcel Plus® products, Aetna Health Network OptionSM products, Aetna Choice®, Aetna Choice® POS II, Aetna MedicareSM Plan (PPO), Aetna Open Access® Managed Choice®, and Quality Point-of-Service® (QPOS®) benefits plans may include the option for members to elect to go outside the network and receive reduced benefits.