Patient Care Programs & Quality Assurance

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tools for cost estimates and fee schedules">Try our cost tools</a></p> </div> </div> </section> <section class="cmp-secondarynavitem__featured-parsys"> </section> </li> </ul> <ul class="cmp-navitem__secondary-menu-block cmp-navitem__secondary-menu-block--3"> <li role="none" class="cmp-secondarynavitem cmp-secondarynavitem--featured-content"> <section class="cmp-secondarynavitem__featured-image"> <img class=" lazyload" data-src="/content/dam/aetna/asset-libraries/pictograms_2021/Pictogram_onWhite_Governance-Compliance.svg" alt/> </section> <section class="cmp-secondarynavitem__featured-text"> <div><div class="rte-component-wraper component--default "> <h2><span class="title--secondary__big">Disputes and appeals</span></h2> <p><br /> If you disagree with our decision, we’re here to help you with the next steps.</p> <p> </p> <p><a data-analytics-name="Learn how to submit an appeal" href="/health-care-professionals/disputes-appeals.html" class="link__text">Learn how to submit an 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class="cmp-secondarynavitem cmp-secondarynavitem--featured-content"> <section class="cmp-secondarynavitem__featured-image"> <img class=" lazyload" data-src="/content/dam/aetna/asset-libraries/pictograms_2021/Pictogram_onWhite_Multi_dose_packaging.svg" alt/> </section> <section class="cmp-secondarynavitem__featured-text"> <div><div class="rte-component-wraper component--default "> <h2><span class="title--secondary__big">Pharmacy services</span></h2> <p> </p> <p>Information on prescribing tools, specialty drugs, how to submit a claim and more.</p> <p> </p> <p><a data-analytics-name="Find pharmacy services" href="/health-care-professionals/pharmacy-services.html" class="link__text">Find pharmacy services</a></p> </div> </div> </section> <section class="cmp-secondarynavitem__featured-parsys"> </section> </li> </ul> <ul class="cmp-navitem__secondary-menu-block cmp-navitem__secondary-menu-block--3"> <li role="none" class="cmp-secondarynavitem cmp-secondarynavitem--featured-content"> <section 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rte-component-wraper mb-0"><p>Patient care support and quality go hand in hand.</p> </div>    <div> </div> </div> </div> </div> </div> </div> </div> </div> <div class="textwithmedia"><div class="textmedia " data-cmp-is-async="textwithmedia/one" data-content-well="yes" data-disablereadmore="true"> <div class="container textmedia__componentwrapper textmedia--one component--right textmedia--one--small"> <div class="row"> <div class="col-12 d-md-none"> <h2 class="title__block title--mobile">Resources and support for behavioral health care</h2> </div> <div class="col-md-6 col-lg-6 mediawrapper--right"> <div class="textmedia__wrapper"> <h2 class="d-none d-md-block title__block">Resources and support for behavioral health care</h2> <div class="textmedia__wrapper--inner"> <div class="textmedia__text textmedia__text--top body__copy"><div class="textdescription text"><div class="rte-component-wraper component--default "> <p>Many patients feel most comfortable learning about treatment options 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These patient care programs can help primary care providers obtain specialized care for patients with certain behavioral health conditions.</p> </div> </div> </div> </div> <div> <div class="component__cta"> <div data-cmp-is="cta"> <ul class="cta__linkswrapper"> <li class="type__link__text--secondary"> <a class="link__text--secondary " href="/health-care-professionals/patient-care-programs/depression-primary-care-program.html" data-modal="Please Select" data-linktype="Regular" target="_self" role="link" data-analytics-name="Depression in primary care" data-linklocation="discoverable" data-ctahrefholder="/content/aetna/en/health-care-professionals/patient-care-programs/depression-primary-care-program.html">Depression in primary care</a> </li> <li class="type__link__text--secondary"> <a class="link__text--secondary " href="/health-care-professionals/patient-care-programs/alcohol-screening-intervention.html" data-modal="Please Select" data-linktype="Regular" target="_self" role="link" data-analytics-name="Alcohol and drug use screening, brief intervention and referral to treatment" data-linklocation="discoverable" data-ctahrefholder="/content/aetna/en/health-care-professionals/patient-care-programs/alcohol-screening-intervention.html">Alcohol and drug use screening, brief intervention and referral to treatment</a> </li> </ul> </div> </div> </div> </div> </div> <div class="col-md-4 col-lg-4 mediawrapper__small__xsmall mediawrapper--left"> <div class="mediacontainer__slot1 "> <div data-src="/content/dam/aetna/asset-libraries/photos/GettyImages-580817241_696x522.jpg" class="media__one__image media--hide"></div> <div class="media__one media__image--horizontal" data-slot1-image-loaded="false"> <div class="media__content media__image--animate"> <img class=" lazyload" data-src="/content/dam/aetna/asset-libraries/photos/GettyImages-580817241_696x522.jpg" alt width="696" height="522"/> </div> </div> </div> </div> </div> </div> </div> </div> <div class="textwithmedia"><div class="textmedia " data-cmp-is-async="textwithmedia/one" data-content-well="yes" data-disablereadmore="true"> <div class="container textmedia__componentwrapper textmedia--one component--left textmedia--one--small"> <div class="row"> <div class="col-12 d-md-none"> <h2 class="title__block title--mobile">Connecting patients with the right care</h2> </div> <div class="col-md-4 col-lg-4 mediawrapper__small__xsmall mediawrapper--left"> <div class="mediacontainer__slot1 "> <div data-src="/content/dam/aetna/asset-libraries/photos/GettyImages-1320789641_696x522.jpg" class="media__one__image media--hide"></div> <div class="media__one media__image--horizontal" data-slot1-image-loaded="false"> <div class="media__content media__image--animate"> <img class=" lazyload" data-src="/content/dam/aetna/asset-libraries/photos/GettyImages-1320789641_696x522.jpg" alt width="696" height="522"/> </div> </div> </div> </div> <div class="col-md-6 col-lg-6 mediawrapper--right"> <div class="textmedia__wrapper"> <h2 class="d-none d-md-block title__block">Connecting patients with the right care</h2> <div class="textmedia__wrapper--inner"> <div class="textmedia__text textmedia__text--top body__copy"><div class="textdescription text"><div class="rte-component-wraper component--default "> <p>It's important to choose the right care for patients with behavioral health needs. These tools can help:</p> <p> </p> <ul> <li>Level of Care Utilization System (LOCUS)</li> <li>Child and Adolescent Level of Care Utilization System/Child and Adolescent Service Intensity Instrument (CALOCUS/CASII) </li> <li>Applied Behavioral Analysis (ABA) Medical Necessity Guide</li> <li>American Society of Addiction Medicine (ASAM) Treatment Criteria</li> </ul> </div> </div> </div> </div> <div> <div class="component__cta"> <div data-cmp-is="cta"> <div class="cta__linkswrapper"> <a class="link__text type__link__text " href="/health-care-professionals/patient-care-programs/locat-aba-guidelines.html" data-modal="Please Select" data-linktype="Regular" target="_self" role="link" data-analytics-name="Learn more about behavioral health guidelines" data-linklocation="discoverable" data-ctahrefholder="/content/aetna/en/health-care-professionals/patient-care-programs/locat-aba-guidelines.html">Learn more about behavioral health guidelines</a> </div> </div> </div> </div> </div> </div> </div> </div> </div> </div> <div class="nextbestaction"><div class="cmp-nextbestaction nextaction " data-cmp-is-css="nba/nextbestaction" data-content-well="yes"> <div class="container nextaction__wrapper"> <div class="row "> <div class="col-md-12"> <div class="row"> <div class="col col-lg-6 nextaction__block--title "> <h2 class="title__block">Commitment to quality</h2> </div> </div> </div> <div class="col-lg-3 col-md-6 nextaction__block--withtitle nextaction__block link--textline"> <div class="nextaction__top"> <div class="nextaction__top__headline"> <h3 class="intro__copy">Quality report cards</h3> </div> </div> <div class="nextaction__body"> <div class="nextaction__body__description rte-component-wraper"> <p>Report cards rate the quality of our health plans in multiple areas. 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The ABA Medical Necessity Guide does not constitute medical advice. Treating providers are solely responsible for medical advice and treatment of members. Members should discuss any matters related to their coverage or condition with their treating provider.</p> <p>Each benefit plan defines which services are covered, which are excluded, and which are subject to dollar caps or other limits. Members and their providers will need to consult the member's benefit plan to determine if there are any exclusions or other benefit limitations applicable to this service or supply.</p> <p>The conclusion that a particular service or supply is medically necessary does not constitute a representation or warranty that this service or supply is covered (i.e., will be 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 considers medically necessary.</p> <p>Please note also that the ABA Medical Necessity Guide may be updated and are, therefore, subject to change.</p> <p>Medical necessity determinations in connection with coverage decisions are made on a case-by-case basis. In the event that a member disagrees with a coverage determination, member may be eligible for the right to an internal appeal and/or an independent external appeal in accordance with applicable federal or state law.</p> </div> </div> </div> <div class="component__cta "> <a href="#" class="modalContinueBtn btn--primary type__btn--primary ">I Accept</a> </div> </div> </div> </div> </div> </div> <div class="interstitial section"><div class="aetna-modal" data-cmp-is="modal"> <div class="modal__box " id="exit-cvs-caremark" role="dialog" title="Aetna® is proud to be part of the CVS® family." tabindex="-1" aria-labelledby="modal-heading-28807244"> <div class="modal__inner"> <button type="button" aria-label="Close" class="modal__close"></button> <div class="modal__content">  <h2 id="modal-heading-28807244" class="title__block ">Aetna® is proud to be part of the CVS® family.</h2> <div class="component__main"> <div class="text"><div class="rte-component-wraper component--default "> <p>You are now being directed to CVS Caremark<sup>®</sup> site.</p> </div> </div> </div> <div class="component__cta "> <a href="#" class="modalContinueBtn btn--primary type__btn--primary ">Continue</a> </div> </div> </div> </div> </div> </div> <div class="interstitial section"><div class="aetna-modal" data-cmp-is="modal"> <div class="modal__box modal--blocked " id="asam-modal" role="dialog" title="ASAM Terms and conditions" tabindex="-1" aria-labelledby="modal-heading-1817940071"> <div class="modal__inner"> <button type="button" aria-label="Close" class="modal__close"></button> <div class="modal__content">  <h2 id="modal-heading-1817940071" class="title__block ">ASAM Terms and conditions</h2> <div class="component__main"> <div class="text"><div class="rte-component-wraper component--default "> <p>By clicking on “I accept”, I acknowledge and accept that:</p> <p> </p> </div> </div> <div class="text"><div class="rte-component-wraper component--default "> <p>Licensee's use and interpretation of the American Society of Addiction Medicine’s ASAM Criteria for Addictive, Substance-Related, and Co-Occurring Conditions does not imply that the American Society of Addiction Medicine has either participated in or concurs with the disposition of a claim for benefits.</p> <p> </p> <p>This excerpt is provided for use in connection with the review of a claim for benefits and may not be reproduced or used for any other purpose.</p> <p> </p> <p>Copyright 2015 by the American Society of Addiction Medicine. Reprinted with permission. No third party may copy this document in whole or in part in any format or medium without the prior written consent of ASAM.</p> </div> </div> </div> <div class="component__cta "> <a href="#" class="modalContinueBtn btn--primary type__btn--primary ">I accept</a> </div> </div> </div> </div> </div> </div> <div class="interstitial section"><div class="aetna-modal" data-cmp-is="modal"> <div class="modal__box modal--blocked " id="cpt-modal" role="dialog" title="Precertification lists" tabindex="-1" aria-labelledby="modal-heading-1737369633"> <div class="modal__inner"> <button type="button" aria-label="Close" class="modal__close"></button> <div class="modal__content">  <h2 id="modal-heading-1737369633" class="title__block ">Precertification lists</h2> <div class="component__main"> <div class="text"><div class="rte-component-wraper component--default "> <p>By clicking on “I accept”, I acknowledge and accept that:</p> <p> </p> </div> </div> <div class="text"><div class="rte-component-wraper component--default "> <p>Should the following terms and conditions be acceptable to you, please indicate your agreement and acceptance by selecting the button below labeled "I Accept".</p> <p> </p> <ul> <li>The term precertification here means the utilization review process to determine whether the requested service, procedure, prescription drug or medical device meets the company's clinical criteria for coverage. It does not mean precertification as defined by Texas law, as a reliable representation of payment of care or services to fully insured HMO and PPO members.</li> <li>Applies to: Aetna Choice<sup>®</sup> POS, Aetna Choice POS II, Aetna Medicare<sup>℠</sup> Plan (PPO), Aetna Medicare Plan (HMO), all Aetna HealthFund<sup>®</sup> products, Aetna Health Network Only<sup>℠</sup>, Aetna Health Network Option<sup>℠</sup>, Aetna Open Access<sup>®</sup> Elect Choice<sup>®</sup>, Aetna Open Access HMO, Aetna Open Access Managed Choice<sup>®</sup>, Open Access Aetna Select<sup>℠</sup>, Elect Choice, HMO, Managed Choice POS, Open Choice<sup>®</sup>, Quality Point-of-Service<sup>®</sup> (QPOS<sup>®</sup>), and Aetna Select<sup>℠</sup> benefits plans and all products that may include the Aexcel<sup>®</sup>, Choose and Save<sup>℠</sup>, Aetna Performance Network or Savings Plus networks. Not all plans are offered in all service areas.</li> <li>All services deemed "never effective" are excluded from coverage. Aetna defines a service as "never effective" when it is not recognized according to professional standards of safety and effectiveness in the United States for diagnosis, care or treatment. Visit the secure website, available through www.aetna.com, for more information. Click on "Claims," "CPT/HCPCS Coding Tool," "Clinical Policy Code Search."</li> <li>The five character codes included in the Aetna Precertification Code Search Tool are obtained from Current Procedural Terminology (CPT<sup>®</sup>), copyright 2023 by the American Medical Association (AMA). CPT is developed by the AMA as a listing of descriptive terms and five character identifying codes and modifiers for reporting medical services and procedures performed by physicians.</li> <li>The responsibility for the content of Aetna Precertification Code Search Tool is with Aetna and no endorsement by the AMA is intended or should be implied. The AMA disclaims responsibility for any consequences or liability attributable or related to any use, nonuse or interpretation of information contained in Aetna Precertification Code Search Tool. No fee schedules, basic unit values, relative value guides, conversion factors or scales are included in any part of CPT. Any use of CPT outside of Aetna Precertification Code Search Tool should refer to the most Current Procedural Terminology which contains the complete and most current listing of CPT codes and descriptive terms. Applicable FARS/DFARS apply.</li> </ul> <p> </p> <h3><strong>LICENSE FOR USE OF CURRENT PROCEDURAL TERMINOLOGY, FOURTH EDITION ("CPT<sup>®</sup>")</strong></h3> <p> </p> <ul> <li>CPT only Copyright 2023 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 Precertification Code Search Tool solely for your own personal use in directly participating in health care programs administered by Aetna, Inc. You acknowledge that AMA holds all copyright, trademark and other rights in CPT. Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CPT for resale and/or license, transferring copies of CPT to any party not bound by this agreement, creating any modified or derivative work of CPT, or making any commercial use of CPT. License to sue 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 at the American Medical Association Web site, www.ama-assn.org/go/cpt.</li> </ul> <p> </p> <h3><strong>U.S. Government Rights</strong></h3> <p> </p> <ul> <li>This product includes CPT which is commercial technical data and/or computer data bases and/or commercial computer software and/or commercial computer software documentation, as applicable which were developed exclusively at private expense by the American Medical Association, 515 North State Street, Chicago, Illinois, 60610. U.S. Government rights to use, modify, reproduce, release, perform, display, or disclose these technical data and/or computer data bases and/or computer software and/or computer software documentation are subject to the limited rights restrictions of DFARS 252.227-7015(b)(2) (June 1995) and/or subject to the restrictions of DFARS 227.7202-1(a) (June 1995) and DFARS 227.7202-3(a) (June 1995), as applicable for U.S. Department of Defense procurements and the limited rights restrictions of FAR 52.227-14 (June 1987) and/or subject to the restricted rights provisions of FAR 52.227-14 (June 1987) and FAR 52.227-19 (June 1987), as applicable, and any applicable agency FAR Supplements, for non-Department of Defense Federal procurements.</li> </ul> <p> </p> <h3><strong>Disclaimer of Warranties and Liabilities.</strong></h3> <p> </p> <ul> <li>CPT is provided "as is" without warranty of any kind, either expressed or implied, including but not limited to the implied warranties of merchantability and fitness for a particular purpose. No fee schedules, basic unit, relative values or related listings are included in CPT. The American Medical Association (AMA) does not directly or indirectly practice medicine or dispense medical services. The responsibility for the content of this product is with Aetna, Inc. and no endorsement by the AMA is intended or implied. The AMA disclaims responsibility for any consequences or liability attributable to or related to any use, non-use, or interpretation of information contained or not contained in this product.</li> <li>This Agreement will terminate upon notice if you violate its terms. The AMA is a third party beneficiary to this Agreement.</li> <li>Should the foregoing terms and conditions be acceptable to you, please indicate your agreement and acceptance by selecting the button labeled "I Accept".</li> <li>The information contained on this website and the products outlined here may not reflect product design or product availability in Arizona. Therefore, Arizona residents, members, employers and brokers must contact Aetna directly or their employers for information regarding Aetna products and services.</li> <li>This information is neither an offer of coverage nor medical advice. It is only a partial, general description of plan or program benefits and does not constitute a contract. In case of a conflict between your plan documents and this information, the plan documents will govern.</li> </ul> </div> </div> </div> <div class="component__cta "> <a href="#" class="modalContinueBtn btn--primary type__btn--primary ">I accept</a> </div> </div> </div> </div> </div> </div> <div class="interstitial section"><div class="aetna-modal" data-cmp-is="modal"> <div class="modal__box modal--blocked " id="dcpb-modal" role="dialog" title="Dental clinical policy bulletins" tabindex="-1" aria-labelledby="modal-heading-1767983030"> <div class="modal__inner"> <button type="button" aria-label="Close" class="modal__close"></button> <div class="modal__content">  <h2 id="modal-heading-1767983030" class="title__block ">Dental clinical policy bulletins</h2> <div class="component__main"> <div class="text"><div class="rte-component-wraper component--default "> <p>By clicking on “I accept”, I acknowledge and accept that:</p> <p> </p> </div> </div> <div class="text"><div class="rte-component-wraper component--default "> <ul> <li>Aetna Dental Clinical Policy Bulletins (DCPBs) are developed to assist in administering plan benefits and do not constitute dental advice. Treating providers are solely responsible for dental advice and treatment of members. Members should discuss any Dental Clinical Policy Bulletin (DCPB) related to their coverage or condition with their treating provider.</li> <li>While the Dental Clinical Policy Bulletins (DCPBs) are developed to assist in administering plan benefits, they do not constitute a description of plan benefits. The Dental Clinical Policy Bulletins (DCPBs) describe Aetna's current determinations of whether certain services or supplies are medically necessary, based upon a review of available clinical information. Each benefit plan defines which services are covered, which are excluded, and which are subject to dollar caps or other limits. Members and their providers will need to consult the member's benefit plan to determine if there are any exclusions or other benefit limitations applicable to this service or supply. Aetna's conclusion that a particular service or supply is medically necessary does not constitute a representation or warranty that this service or supply is covered (i.e., will be paid for by Aetna). Your benefits plan determines coverage. Some plans exclude coverage for services or supplies that Aetna considers medically necessary. If there is a discrepancy between this policy and a member's plan of benefits, the benefits plan will govern. In addition, coverage may be mandated by applicable legal requirements of a State or the Federal government.</li> <li>Please note also that Dental Clinical Policy Bulletins (DCPBs) are regularly updated and are therefore subject to change.</li> <li>Since Dental Clinical Policy Bulletins (DCPBs) can be highly technical and are designed to be used by our professional staff in making clinical determinations in connection with coverage decisions, members should review these Bulletins with their providers so they may fully understand our policies.</li> <li>Under certain plans, if more than one service can be used to treat a covered person's dental condition, Aetna may decide to authorize coverage only for a less costly covered service provided that certain terms are met.</li> </ul> </div> </div> </div> <div class="component__cta "> <a href="#" class="modalContinueBtn btn--primary type__btn--primary ">I accept</a> </div> </div> </div> </div> </div> </div> <div class="interstitial section"><div class="aetna-modal" data-cmp-is="modal"> <div class="modal__box modal--blocked " id="mcpbs-modal" role="dialog" title="Medical clinical policy bulletins" tabindex="-1" aria-labelledby="modal-heading-1142802819"> <div class="modal__inner"> <button type="button" aria-label="Close" class="modal__close"></button> <div class="modal__content">  <h2 id="modal-heading-1142802819" class="title__block ">Medical clinical policy bulletins</h2> <div class="component__main"> <div class="text"><div class="rte-component-wraper component--default "> <p>By clicking on “I accept”, I acknowledge and accept that:</p> <p> </p> </div> </div> <div class="text"><div class="rte-component-wraper component--default " data-linklocationGeneral="discoverable"> <p>Should the following terms and conditions be acceptable to you, please indicate your agreement and acceptance by selecting the button below labeled "I Accept".</p> <p> </p> <ul> <li>Aetna Clinical Policy Bulletins (CPBs) are developed to assist in administering plan benefits and do not constitute medical advice. Treating providers are solely responsible for medical advice and treatment of members. Members should discuss any Clinical Policy Bulletin (CPB) related to their coverage or condition with their treating provider.</li> <li>While the Clinical Policy Bulletins (CPBs) are developed to assist in administering plan benefits, they do not constitute a description of plan benefits. The Clinical Policy Bulletins (CPBs) express Aetna's determination of whether certain services or supplies are medically necessary, experimental, investigational, unproven, or cosmetic. Aetna has reached these conclusions based upon a review of currently available clinical information (including clinical outcome studies in the peer-reviewed published medical literature, regulatory status of the technology, evidence-based guidelines of public health and health research agencies, evidence-based guidelines and positions of leading national health professional organizations, views of physicians practicing in relevant clinical areas, and other relevant factors).</li> <li>Aetna makes no representations and accepts no liability with respect to the content of any external information cited or relied upon in the Clinical Policy Bulletins (CPBs). The discussion, analysis, conclusions and positions reflected in the Clinical Policy Bulletins (CPBs), including any reference to a specific provider, product, process or service by name, trademark, manufacturer, constitute Aetna's opinion and are made without any intent to defame. Aetna expressly reserves the right to revise these conclusions as clinical information changes, and welcomes further relevant information including correction of any factual error.</li> <li>CPBs include references to standard HIPAA compliant code sets to assist with search functions and to facilitate billing and payment for covered services. New and revised codes are added to the CPBs as they are updated. When billing, you must use the most appropriate code as of the effective date of the submission. Unlisted, unspecified and nonspecific codes should be avoided.</li> <li>Each benefit plan defines which services are covered, which are excluded, and which are subject to dollar caps or other limits. Members and their providers will need to consult the member's benefit plan to determine if there are any exclusions or other benefit limitations applicable to this service or supply. The conclusion that a particular service or supply is medically necessary does not constitute a representation or warranty that this service or supply is covered (i.e., will be 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 considers medically necessary. If there is a discrepancy between a Clinical Policy Bulletin (CPB) and a member's plan of benefits, the benefits plan will govern.</li> <li>In addition, coverage may be mandated by applicable legal requirements of a State, the Federal government or CMS for Medicare and Medicaid members. </li> </ul> <p><a href="https://www.cms.gov/Center/special-topic/medicare-coverage-center.html" target="_blank" class="link__text" data-analytics-name="See CMS's Medicare Coverage Center" data-modal="exit" data-linktype="Regular">See CMS's Medicare Coverage Center</a></p> <p> </p> <ul> <li>Please note also that Clinical Policy Bulletins (CPBs) are regularly updated and are therefore subject to change.</li> <li>Since Clinical Policy Bulletins (CPBs) can be highly technical and are designed to be used by our professional staff in making clinical determinations in connection with coverage decisions, members should review these Bulletins with their providers so they may fully understand our policies. Under certain circumstances, your physician may request a peer to peer review if they have a question or wish to discuss a medical necessity precertification determination made by our medical director in accordance with Aetna’s Clinical Policy Bulletin.</li> <li>While Clinical Policy Bulletins (CPBs) define Aetna's clinical policy, medical necessity determinations in connection with coverage decisions are made on a case by case basis. In the event that a member disagrees with a coverage determination, Aetna provides its members with the right to appeal the decision. In addition, a member may have an opportunity for an independent external review of coverage denials based on medical necessity or regarding the experimental and investigational status when the service or supply in question for which the member is financially responsible is $500 or greater. However, applicable state mandates will take precedence with respect to fully insured plans and self-funded non-ERISA (e.g., government, school boards, church) plans.</li> </ul> <p><a href="/individuals-families/member-rights-resources/claims-coverage/aetna-external-review-program.html" target="_self" class="link__text" data-analytics-name="See Aetna's External Review Program" data-modal="Please Select" data-linktype="Regular">See Aetna's External Review Program</a></p> <p> </p> <ul> <li>The five character codes included in the Aetna Clinical Policy Bulletins (CPBs) are obtained from Current Procedural Terminology (CPT®), copyright 2015 by the American Medical Association (AMA). CPT is developed by the AMA as a listing of descriptive terms and five character identifying codes and modifiers for reporting medical services and procedures performed by physicians.</li> <li>The responsibility for the content of Aetna Clinical Policy Bulletins (CPBs) is with Aetna and no endorsement by the AMA is intended or should be implied. The AMA disclaims responsibility for any consequences or liability attributable or related to any use, nonuse or interpretation of information contained in Aetna Clinical Policy Bulletins (CPBs). No fee schedules, basic unit values, relative value guides, conversion factors or scales are included in any part of CPT. Any use of CPT outside of Aetna Clinical Policy Bulletins (CPBs) should refer to the most current Current Procedural Terminology which contains the complete and most current listing of CPT codes and descriptive terms. Applicable FARS/DFARS apply.</li> </ul> <p> </p> <h3>LICENSE FOR USE OF CURRENT PROCEDURAL TERMINOLOGY, FOURTH EDITION ("CPT®")</h3> <p> </p> <p>CPT only copyright 2015 American Medical Association. All Rights Reserved. CPT is a registered trademark of the American Medical Association.</p> <p> </p> <p>You, your employees and agents are authorized to use CPT only as contained in Aetna Clinical Policy Bulletins (CPBs) solely for your own personal use in directly participating in healthcare programs administered by Aetna, Inc. You acknowledge that AMA holds all copyright, trademark and other rights in CPT.</p> <p> </p> <p>Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CPT for resale and/or license, transferring copies of CPT to any party not bound by this agreement, creating any modified or derivative work of CPT, or making any 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 at the American Medical Association Web site, www.ama-assn.org/go/cpt.</p> <p> </p> <p><a href="http://www.ama-assn.org/go/cpt" target="_blank" class="link__text" data-analytics-name="Go to the American Medical Association Web site" data-modal="exit" data-linktype="Regular">Go to the American Medical Association Web site</a></p> <p> </p> <h3><strong>U.S. Government Rights</strong></h3> <p> </p> <p>This product includes CPT which is commercial technical data and/or computer data bases and/or commercial computer software and/or commercial computer software documentation, as applicable which were developed exclusively at private expense by the American Medical Association, 515 North State Street, Chicago, Illinois, 60610. U.S. Government rights to use, modify, reproduce, release, perform, display, or disclose these technical data and/or computer data bases and/or computer software and/or computer software documentation are subject to the limited rights restrictions of DFARS 252.227-7015(b)(2) (June 1995) and/or subject to the restrictions of DFARS 227.7202-1(a) (June 1995) and DFARS 227.7202-3(a) (June 1995), as applicable for U.S. Department of Defense procurements and the limited rights restrictions of FAR 52.227-14 (June 1987) and/or subject to the restricted rights provisions of FAR 52.227-14 (June 1987) and FAR 52.227-19 (June 1987), as applicable, and any applicable agency FAR Supplements, for non-Department of Defense Federal procurements.</p> <p> </p> <h3><strong>Disclaimer of Warranties and Liabilities.</strong></h3> <p> </p> <p>CPT is provided "as is" without warranty of any kind, either expressed or implied, including but not limited to the implied warranties of merchantability and fitness for a particular purpose. No fee schedules, basic unit, relative values or related listings are included in CPT. The American Medical Association (AMA) does not directly or indirectly practice medicine or dispense medical services. The responsibility for the content of this product is with Aetna, Inc. and no endorsement by the AMA is intended or implied. The AMA disclaims responsibility for any consequences or liability attributable to or related to any use, non-use, or interpretation of information contained or not contained in this product.</p> <p> </p> <p>This Agreement will terminate upon notice if you violate its terms. The AMA is a third party beneficiary to this Agreement.</p> <p> </p> <p>Should the foregoing terms and conditions be acceptable to you, please indicate your agreement and acceptance by selecting the button labeled "I Accept".</p> <p> </p> <p>The information contained on this website and the products outlined here may not reflect product design or product availability in Arizona. Therefore, Arizona residents, members, employers and brokers must contact Aetna directly or their employers for information regarding Aetna products and services.</p> <p> </p> <p>This information is neither an offer of coverage nor medical advice. It is only a partial, general description of plan or program benefits and does not constitute a contract. In case of a conflict between your plan documents and this information, the plan documents will govern.</p> </div> </div> </div> <div class="component__cta "> <a href="#" class="modalContinueBtn btn--primary type__btn--primary ">I accept</a> </div> </div> </div> </div> </div> </div> <div class="interstitial section"><div class="aetna-modal" data-cmp-is="modal"> <div class="modal__box " id="provault-modal" role="dialog" tabindex="-1" aria-labelledby="modal-heading-307478118"> <div class="modal__inner"> <button type="button" aria-label="Close" class="modal__close"></button> <div class="modal__content">  <h2 id="modal-heading-307478118" class="title__block "></h2> <div class="component__main"> <div class="text"><div class="rte-component-wraper component--default "> <h2><span class="title__block">You are now leaving the Aetna® website.</span></h2> <p> </p> <p>We're working with 3Won to process your request for participation. 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