Medical 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 Golden ChoiceTM , Aetna Golden Medicare Plan®, Aetna Golden Medicare Open Access®, Aetna Golden Medicare Dual Advantage Plan, Aetna Golden Choice Care Advantage, all Aetna HealthFund® products, Aetna Health Network OnlySM, Aetna Health Network OptionSM, Aetna Open Access® Elect Choice®, Aetna Open Access ® HMO, Aetna Open Access® Managed Choice®, Open Access Aetna SelectSM, 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
Review precertification exceptions.

Precertification – Non-Participating Provider Request  (PDF)

Aetna Student Health  (PDF)

Precertification list
Download/Print 2009 Precertification List  (PDF)

1. Inpatient confinements

• Surgical and non-surgical, vaginal or Caesarean deliveries excluding routine†
• Skilled nursing facility
• Rehabilitation facility
• Inpatient hospice (except Medicare)

2. Reconstructive procedures that may be considered cosmetic

• Blepharoplasty/canthopexy/canthoplasty
• Excision of excessive skin due to weight loss
• Rhinoplasty/rhytidectomy
• Gastroplasty/gastric bypass
• Pectus excavatum repair
• Breast reconstruction/breast enlargement
• Breast reduction/mammoplasty
• Surgical treatment of gynecomastia
• Lipectomy or excess fat removal
• 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††

• Stereotactic radiosurgery
• Somatosensory evoked potential studies
• Cognitive skills development
• Hyperbaric oxygen therapy
• Osteochondral allograft/knee
• Cochlear device and/or implantation
• Osseointegrated implant
• Percutaneous implant of neuroelectrode array, epidural
• GI tract imaging through capsule endoscopy
• Botox injections -- botulinum toxin type A
• Alpha 1-proteinase inhibitor -- human
• Negative pressure wound therapy pump
• High-frequency chest wall oscillation generator system
• Onco Type DX

10. Medical injectables

• Synagis, call 1-866-503-0857
• Erythropoesis Stimulating Agents (ESA), such as darbepoetin alpha (Aranesp), epoetin alpha (Epogen and Procrit) and epoetin beta (Micera), call 1-866-503-0857
• Xolair, call 1-866-503-0857 or fax 1-888-267-3277
• Intravenous immunoglobulin (IVIG)
• Growth hormone
• Blood-clotting factors
• Interferons when used for hepatitis C
  • Pegasys®
  • Peg Intron®
  • Rebetron®
  • Roferon A®
  • Intron A®
  • Infergen®

11. All home health care services, including home uterine monitoring

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. Special programs

• To precertify mental health or substance abuse services,  refer to the member’s ID card for the toll-free Member Services or Aetna Behavioral Health phone number. Check the list of services requiring precertification. 
• Beginning RightSM Maternity Program, including genetic testing, antenatal testing, perinatal consultations and counseling: 1-800-272-3531
• BRCA Genetic Testing: 1-877-794-8720
• Infertility Case Management and Education Program: 1-800-575-5999
• Pre-implantation genetic testing: 1-800-575-5999
• Pediatric Congenital Heart Surgery Program: see the member’s ID card to contact the Precertification unit
• 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
• (Where applicable) For all members (with plans applicable to this precert list): Outpatient imaging precertification for CTs, coronary computed tomographic angiography, MRI/MRA, nuclear cardiology, nuclear medicine, PET scans through regional-specific managed service organizations (MedSolutions, Care Core National and National Imaging Associates)
• (Where applicable) For HMO-based plan members only: Chiropractic therapy precertification through regional-specific managed service organizations (American Chiropractic Network, American Specialty Health, Healthways and Triad)
• (Metro NY/NNJ) For HMO-based plan members only: Outpatient physical and occupational therapy precertification through Orthonet at 1-800-771-3205

More information  

• Electronic submission of precertification requests and inquiries is preferred.
• For assistance with precertification, please call the Aetna Voice Advantage® automated phone system using the appropriate phone number below. Select the precertification option:
  • HMO-based benefits plans: call 1-800-624-0756
  • Indemnity and PPO-based benefits plans: call 1-888-632-3862
• For more information, visit Clinical Policy Bulletins and DocFind®.
• For precertification of oral medications, call Aetna Pharmacy Management at 1-800-414-2386.
• For information on injectable medications not listed, call 1-866-782-2779.
• Precertification approvals are valid for six months in all states.
   

*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.

**Aexcel is not available with HMO plans. Aexcel designation is only a guide to choosing a physician.  Members should confer with their existing physicians before making a decision.  Designations have the risk of error and should not be the sole basis for selecting a doctor.

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

†Routine Delivery
     A total length of stay of 3 days or less for vaginal deliveries
     A total length of stay of 5 days or less for a Caesarean 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 Option products, Aetna Choice, Choice POS II, Golden Choice Plan, Open Access Managed Choice, QPOS and USAccess benefits plans may include the option for members to elect to go outside the network and receive reduced benefits.