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Utilization Management

How we determine coverage

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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 Guidelines© for the Treatment of Autism Spectrum Disorders
  • Level of Care Assessment Tool (LOCAT)

See our Clinical Policy Bulletins
Learn more about ABA, ASAM and LOCAT
Medicare Notice of Coverage Determinations

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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)

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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