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New preapproval requirements for Medicare Advantage PPO members


We’re working with MedSolutions doing business as eviCore healthcare, to authorize many procedures in our Enhanced Clinical Review Program. The program became effective on November 1, 2018, for California members in our Medicare Advantage PPO Aetna-branded products. Below are the services that will and will not require preapproval.


Services that require preapproval

 

  • High-tech outpatient diagnostic imaging procedures; these include MRI/MRA, nuclear cardiology, and PET scan and CT scan, including CTA.
  • Nonemergent outpatient stress echocardiography.
  • Nonemergent outpatient diagnostic left and right heart catheterization.
  • Insertion, removal and upgrade of elective implantable cardioverter-defibrillators (ICDs), cardiac resynchronization therapy defibrillators (CRT-Ds) and implantable pacemakers.
  • Polysomnography (attended sleep studies).
  • Interventional pain management.
  • Musculoskeletal large joint (hip and knee) arthroplasty procedures.


Services that do not require preapproval

 

  • Inpatient radiology services.
  • Emergency room radiology services.
  • Outpatient radiology services other than those listed above.


How to request preapproval

 

  • Visit eviCore healthcare.
  • Call 1-888-693-3211 during normal business hours.
  • Fax a request form (available online) to 1-888-693-3210.


Have questions or need information?

See eviCore healthcare’s criteria and get request forms.