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Utilization management

How we determine coverage


Guidelines for coverage determination

Coverage determination is based on guidelines or criteria that include:

  • Aetna’s Clinical Policy Bulletins
  • Centers for Medicare & Medicaid Services National Coverage        Determinations, Local Coverage Determinations And Medicare Benefit Policy Manual
  • Level of Care Utilization System (LOCUS) and the Child and Adolescent Level of Care Utilization System/Child and Adolescent Service Intensity Instrument (CALOCUS/CASII) for medical necessity reviews
  • MCG™ guidelines
  • American Society of Addiction Medicine (ASAM) Criteria; Treatment Criteria for Addictive, Substance-Related, and Co-Occurring Conditions, Third Edition
  • Applied Behavioral Analysis (ABA) Medical Necessity Guide

See our Clinical Policy Bulletins

Learn more about LOCUS, CALOCUS/CASII, ABA and ASAM

Medicare Notice of Coverage Determinations

Outside vendors

In some states, we delegate utilization review of certain services, including radiology and physical/occupational therapy, to vendors.

CareCore National - DBA eviCoreHealthcare
MedSolutions - DBA eviCoreHealthcare
MedSolutions - DBA eviCoreHealthcare - eviCore clinical guidelines

Drug infusion site of care policy

Aetna’s site of care policy provides the criteria we use to determine the medical necessity of hospital outpatient infusion of IVIG and Solaris.

Read the drug infusion site of care policy

Concurrent review

Sometimes utilization management takes place during inpatient care or outpatient treatment.

Learn more about concurrent review

Retrospective review

In a retrospective review, coverage is determined after treatment has occurred.

Learn more about retrospective review

Note: More stringent state requirements may supersede the requirements of this policy.

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