How we determine coverage
Coverage determination is based on guidelines or criteria that include:
See our Clinical Policy Bulletins
Learn more about ABA, ASAM and LOCAT
Medicare Notice of Coverage Determinations
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
OrthoNet
Aetna’s site of care policy provides the criteria we use to determine the medical necessity of hospital outpatient infusion of IVIG and Solaris.
Sometimes utilization management takes place during inpatient care or outpatient treatment.
In a retrospective review, coverage is determined after treatment has occurred.
Note: More stringent state requirements may supersede the requirements of this policy.
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