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 MedicareSM Plan (PPO), Aetna MedicareSM Plan (HMO), Aetna Medicare Dual AdvantageSM Plan (HMO), 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 SelectSM 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)
- Inpatient confinements
- Surgical and non-surgical
- Including vaginal or Caesarean deliveries excluding routine delivery ***
- Skilled nursing facility
- Rehabilitation facility
- Inpatient hospice (except Medicare)
- 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
- Artificial intervertebral disc surgery
- Lumbar spinal fusion surgery
- Uvulopalatopharyngoplasty, including laser-assisted procedures
- Orthognathic surgery procedures, bone grafts, osteotomies and surgical management of the temporomandibular joint
- Dental implants and oral appliances
- Elective (non-emergent) transportation by ambulance or medical van, and all transfers via air ambulance
- 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
- 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®
- All home health care services, including home uterine monitoring and home hospice
- Selected durable medical equipment
- Electric or motorized wheelchairs and scooters
- Limb prosthetics
- Customized braces
- 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.)
- Nonparticipating free-standing ambulatory surgical facility services, when referred by a participating provider (Effective July 1, 2010).
- Dialysis visits
- Call 1-866-503-0857 or fax applicable request forms to 1-888-267-3277
- 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)
Additional Assistance and Information - 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.