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
- Level of Care Assessment Tool (LOCAT)
See our Clinical Policy Bulletins
Learn more about LOCUS, CALOCUS/CASII, ABA, ASAM and LOCAT
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
OrthoNet
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.
Concurrent review
Sometimes utilization management takes place during inpatient care or outpatient treatment.
Retrospective review
In a retrospective review, coverage is determined after treatment has occurred.
Note: More stringent state requirements may supersede the requirements of this policy.