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
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
Level of Care Assessment Tool (LOCAT)

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

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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Do you have Aetna insurance through an employer or are you a Medicare member? Yes No

Do you have Aetna insurance through an employer or are you a Medicare member? Yes No