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Learn how Aetna makes coverage decisions

Understand medical necessity, Clinical Policy Bulletins and more.

For care to be covered under your health benefits plan, it must meet certain criteria.

“Medical necessity” or “medically necessary” are terms used to describe certain health care or dental services, supplies or medicines that a health care provider would typically give to a patient to prevent, assess, diagnose or treat a specific health issue.

Let’s use this example: surgery on the nose. Some people have this type of surgery to make it easier to breathe, so it’s a medical necessity. Others want a different look, so it’s cosmetic. Or maybe the surgery is being done with a new type of technology, making it experimental and investigational. The category of the surgery affects whether it’s covered by your plan. That’s true of other medical and dental procedures, supplies and medicines, too.

What is a medical necessity?

Usually, for a course of action to be medically necessary, it must be:

  • Based on high-quality research
  • Recognized by the medical or dental community
  • Given in the recommended dose, timing and approach
  • Needed mostly for the health of the patient, not the convenience of the patient or provider(s)
  • Priced the same as or less than other actions offering the same results

Medical and dental services and treatments that don’t meet these criteria may be (1) experimental and investigational or (2) cosmetic. Experimental and investigational health services and treatments are not proven safe and effective, such as medicines in clinical trials. Cosmetic services and treatments are those mainly done to change how someone looks. Some procedures might be both cosmetic and experimental and investigational, such as a new type of cosmetic surgery.

How does this affect medical coverage?

Health insurers use these criteria to develop documents called Clinical Policy Bulletins (CPBs). These CPBs express why certain services or supplies are considered to be medically necessary, experimental and investigational, or cosmetic. Some services must meet medical necessity criteria to be covered.

On the other hand, some plans don’t offer coverage for services or supplies that Aetna considers medically necessary. Put another way: Even if a CPB from Aetna says something is medically necessary, if the benefits plan doesn’t say it’s covered, it’s not.

How do I know what’s covered by my plan?

Each benefit plan defines which services are covered, which are excluded, which have dollar caps or other limits, and what special guidelines (like medical necessity) you have to meet.

Bottom line: You and your health care providers must consult the plan documents for your medical or dental plan to find out what is covered for you.

Read the Aetna Clinical Policy Bulletins for medical, dental, pharmacy and clinical policy to learn what services Aetna may or may not cover.