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- Aetna's Clinical Policy Bulletins (CPBs) have been developed to assist in the administration of plan benefits and do not constitute medical advice. Treating providers are solely responsible for providing treatment and medical advice to members. Members should discuss any Clinical Policy Bulletins (CPB) related to their coverage or condition with their treating provider.
- Although Clinical Policy Bulletins (CPBs) were developed to help administer plan benefits, they are not a description of plan benefits. Clinical Policy Bulletins (CPBs) express Aetna's determination as to whether certain services or supplies are medically necessary, experimental and investigational. or cosmetic. Aetna reached these conclusions based on a review of currently available clinical information (including clinical outcome studies in the peer-reviewed published medical literature, regulatory status of technology, evidence-based public health guidelines, and health research agencies, evidence-based guidelines) . and positions of major national organizations of health professionals, views of physicians practicing in relevant clinical areas, and other relevant factors).
- Aetna makes no representations and assumes no responsibility for the content of any external information cited or relied on in Clinical Policy Bulletins (CPBs). The discussion, analysis, conclusions, and positions expressed in Clinical Policy Bulletins (CPBs), including any reference to a particular provider, product, process, or service by name, trademark, or manufacturer, represent the views of Aetna and They are made without the intent to defame them. Aetna expressly reserves the right to revise these conclusions as clinical information changes and welcomes further relevant information, including corrections of factual errors.
- CPBs contain references to standard HIPAA compliant code sets to support search functionality and facilitate billing and payment for covered services. New and revised codes will be added to the CPBs as they are updated. When invoicing, you must use the most appropriate code on the effective date. Unlisted, unspecified, and unspecific codes should be avoided.
- Each benefit plan defines which benefits are covered, which are excluded, and which are subject to dollar caps or other restrictions. Members and their providers should consult the Member's Benefit Plan to determine if there are any exclusions or other benefit limitations applicable to that service or delivery. The conclusion that a particular service or delivery is medically necessary does not constitute a representation or warranty that that service or delivery will be covered (ie, paid for by Aetna) for a particular Member. The member's benefit plan determines coverage. Some plans exclude coverage for services or supplies that Aetna deems medically necessary. In the event of a discrepancy between a Clinical Policy Bulletin (CPB) and a member's plan of benefits, the plan of benefits will control.
- In addition, coverage may be required by applicable state, federal or CMS legal requirements for Medicare and Medicaid members.
Check out the CMS Medicare Coverage Center
- Please also note that Clinical Policy Bulletins (CPBs) are updated regularly and are therefore subject to change.
- Because Clinical Policy Bulletins (CPBs) can be highly technical and are intended for use by our professional staff in clinical determinations related to coverage decisions, members should review these bulletins with their providers to fully understand our policies.
- While Clinical Policy Bulletins (CPBs) define Aetna's clinical policies, medical necessity decisions related to coverage decisions are made on a case-by-case basis. In the event a member disagrees with a coverage decision, Aetna gives its members the right to appeal the decision. In addition, a member may have the opportunity to have insurance denials verified by an independent third party based on medical necessity or in relation to trial or investigational status when the service or supply in question for which the member is financially responsible is $500 or more. However, applicable government mandates take precedence over fully insured plans and self-funded plans not covered by ERISA (eg, government, school boards, church).
Check out Aetna's External Review Program
- The five-digit codes included in Aetna's Clinical Policy Bulletins (CPBs) are derived from the Current Procedural Terminology (CPT®), Copyright 2015 by the American Medical Association (AMA). The CPT was developed by the AMA as a list of descriptive terms and five-digit identification codes and modifiers to report medical services and procedures performed by physicians.
- Aetna is responsible for the content of Aetna's Clinical Policy Bulletins (CPBs) and no endorsement by the AMA is intended or should be implied. The AMA disclaims any responsibility or liability for any consequence or liability arising from the use, non-use, or interpretation of the information contained in Aetna's Clinical Policy Bulletins (CPBs). No part of the CPT contains a rate table, basic unit values, guide values for relative values, conversion factors or scales. Any use of CPT outside of Aetna's Clinical Policy Bulletins (CPBs) must refer to the most current procedural terminology, which includes the most current and complete list of CPT codes and descriptive terms. Applicable FARS/DFARS apply.
LICENSE TO USE CURRENT PROCEEDING TERMINOLOGY, FOURTH EDITION ("CPT®")
Copyright only CPT 2015 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.
You, your employees and agents are authorized to use CPT only as contained in Aetna's Clinical Policy Bulletins (CPBs) solely for your personal use when directly participating in health care programs administered by Aetna, Inc. You acknowledge that AMA owns all copyrights, trademarks and other rights in CPT.
Any unauthorized use herein is prohibited, including, without limitation, making copies of CPT for resale and/or licensing, transferring copies of CPT to any third party not subject to this Agreement, the realization of works modified or derived from CPT. or commercial use of CPT. License to use CPT for any use not authorized herein must be obtained through the American Medical Association, CPT Intellectual Property Services, 515 N. State Street, Chicago, Illinois 60610. Applications are available on the CPT website. the American Medical Association at www.ama-assn.org/go/cpt.
Go to the American Medical Association website
US Government Rights
This product includes CPT, which is commercial technical data and/or computer databases and/or commercial computer software and/or commercial computer software documentation developed exclusively at private expense by the American Medical Association, 515 North State Street, Chicago, Illinois , 60610. The rights of the US government to use, modify, reproduce, publish, perform, display or disclose this Technical Data and/or the computer database and/or computer software and/or or computer software documentation are subject to the restrictions in DFARS Restricted Rights 252.227-7015 (b)(2) (June 1995) and/or subject to the limitations of DFARS 227.7202-1(a) (June 1995). 1995) and DFARS 227.7202-3(a) (June 1995) as applicable to US Department of Defense acquisitions and the restricted rights of FAR 52.227-14 (June 1987) and/or subject to Statutes of Restricted Rights FAR 5 Amendments 2.227-14 (June 1987) and FAR 52.227-19 (June 1987), as applicable, and any applicable agency FAR Supplements for federal acquisitions outside the Department of Defense.
Disclaimer and Warranty.
CPT is provided "as is" without warranty of any kind, either express or implied, including, but not limited to, the implied warranties of merchantability and fitness for a particular purpose. There are no rate tables, base units, relative values, or related listings in CPT. The American Medical Association (AMA) does not directly or indirectly practice medicine or provide medical services. The contents of this product are the responsibility of Aetna, Inc. and no endorsement by the AMA is intended or implied. WADA disclaims all liability for any consequences or liability arising from the use, non-use, or interpretation of any information contained or not contained in this product.
This Agreement will terminate upon notice if you breach its terms. WADA is a third party beneficiary of this Agreement.
If you find the above terms acceptable, please indicate your acceptance and consent by clicking the "I Agree" button.
The information contained on this website and the products described herein may not reflect the design of the product or the availability of the product in Arizona. Therefore, Arizona residents, members, employers and brokers should contact Aetna or their employers directly for information about Aetna products and services.
This information is not an offer of insurance or medical advice. It is only a partial general description of plan or program benefits and does not constitute a contract. In the event of a conflict between your plan documents and this information, the plan documents will control.