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)
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.
Sometimes utilization management takes place during inpatient care or outpatient treatment.
Note: More stringent state requirements may supersede the requirements of this policy.