How Aetna makes coverage decisions
"Medically Necessary" or "Medical Necessity" are health care or dental services, and supplies or prescription drugs that a physician, other health care provider or dental provider, exercising prudent clinical judgment, would give to a patient for the purpose of preventing, evaluating, diagnosing, or treating an illness, injury, disease, or its symptoms.
The provision of the service, supply or prescription drug must be:
- In accordance with generally accepted standards of medical or dental practice;
- Clinically appropriate, in terms of type, frequency, extent, site and duration, and considered effective for the patient's illness, injury or disease; and
- Not mostly for the convenience of the patient, physician, other health care or dental provider; and
- Do not cost more than an alternative service or sequence of services at least as likely to produce the same therapeutic or diagnostic results as to the diagnosis or treatment of that patient's illness, injury, or disease.
For these purposes “generally accepted standards of medical or dental practice” means standards that are based on credible scientific evidence published in peer-reviewed literature. They must be generally recognized by the relevant medical or dental community. Otherwise, the standards are consistent with physician or dental specialty society recommendations. They must be consistent with the views of physicians or dentists practicing in relevant clinical areas and any other relevant factors.
What are clinical policy bulletins (CPBs)?
Health insurers use these documents to explain the basis for coverage decisions for their members. In them, you can find details about how services are covered, or not covered. You can also find special guidelines that you may have to meet for a service to be covered.
Insurers use objective sources to make these decisions, like expert opinions or scientific literature.
You may hear other terms that mean the same thing as CPBs. One example is "coverage determination guidelines." Another is "medical coverage guidelines."