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Clinical guidelines and policy bulletins

Guidelines

Clinical practice guidelines
 

We adopt evidence-based clinical practice guidelines (CPGs) from nationally recognized sources. The CPGs are tools to help you make decisions about appropriate care for specific clinical circumstances. The CPGs were chosen to help our providers give members high-quality, consistent care with effective use of services and resources. These protocols are reviewed every two years, or more frequently if national guidelines change within a two-year period. 

Preventive care guidelines
 

We adopt nationally accepted, evidence-based preventive health guidelines from the U.S. Preventive Services Task Force and the Centers for Disease Control and Prevention.
 

If these sources have insufficient evidence to recommend for or against a service, or have conflicting interpretations of evidence, we may use recommendations from other nationally recognized sources.

What you should know

These guidelines are intended to improve the delivery of care and clarify standards and expectations. They are for informational purposes only. They should not:
 

  • Take precedence over your responsibility to provide treatment based on individual needs
  • Substitute as orders for treatment of a member
  • Guarantee coverage or payment for the type or level of care proposed or provided

Clinical practice guidelines

Clinical practice guidelines (PDF)

Bright Futures Periodicity Schedule and Coding Matrix (PDF)

 

Validated Screening Tools for Developmental Delays and Autism Spectrum Disorder (PDF)

Guidelines on Use of Opiods to Treat Chronic Noncancer Pain (PDF)

Dental Opioid Prescribing Guidelines (PDF)

Emergency Department Pain Treatment Guidelines (PDF)

We do not routinely conduct post-service reviews. We ask that our providers follow the procedures for requesting prior authorizations, which you can find in:

  • Your provider manual (PDF)
  • Your individual provider contract
  • Our Aetna Better Health® Kids website
  • The written notice to you or the provider

If your request for prior authorization is denied, you should submit a claim and follow the provider appeal process.

Clinical policy bulletins

These bulletins state our policy about the medical necessity or investigational status of medical technologies and other services to help with coverage decisions. A national review team creates the bulletins and bases them on:

 

  • Published medical literature
  • Formal technology assessments
  • Structured evidence reviews
  • Evidence-based consensus statements
  • Expert opinions
  • Evidence-based guidelines from professional and public health entities 

 

Aetna® clinical policy bulletins

 

Aetna medical clinical policy bulletins

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