Guidelines for Determining Coverage | Clinical Policy Bulletins | Medicare | Payment Policy | Dispute Process

• Precertification

• Concurrent Review

• Retrospective Review

Aetna Patient Management staff use evidence-based clinical guidelines from nationally recognized authorities to guide utilization management decisions involving precertification, inpatient review, discharge planning and retrospective review.

With the specific information collected regarding a member's clinical condition, Aetna staff use the following criteria as guides in making coverage determinations as applicable:

• Milliman Care Guidelines^® for medical and surgical care.
• American Association of Oral and Maxillofacial Surgeons (AAOMS) Parameters and Pathways: Clinical Practice Guidelines for Oral and Maxillofacial Surgery.
• Aetna Clinical Policy Bulletins (CPBs), which are based on peer-reviewed published medical literature.
• Centers for Medicare & Medicaid Services (CMS) National Coverage Determinations and Local Coverage Determinations.
• Aetna Level of Care Assessment Tool^® (LOCAT) for behavioral health care.
• American Society of Addiction Medicine Patient Placement Criteria for the Treatment of Substance-Related Disorders (ASAM PPC-2R).
• Texas Commission on Alcohol and Drug Abuse (TCADA) regulations (used in place of ASAM for Texas members).

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:

• CareCore National at www.carecorenational.com.
• National Imaging Associates at www.radmd.com.
• OrthoNet at www.orthonet-online.com.