A member’s benefit plan defines the services that are covered and excluded under the plan. Our professional clinical staff develops clinical policy bulletins to make members and providers aware of our policies on the experimental and investigational status and medical necessity of medical technologies and services. We use these bulletins to guide medical coverage decisions for services and treatments that are covered benefits and those that have no specific exclusion outlined within a specific health plan. In other words, clinical policy bulletins do not guarantee coverage, but define the criteria and status necessary for coverage if that service or treatment is not an excluded benefit.
Clinical effectiveness and safety are the primary criteria we use in determining whether a treatment or service is medically necessary. When effectiveness and safety are equivalent, we may consider the cost-effectiveness among therapies to determine medical necessity or to require certain therapies to be tried before covering equivalent, but more expensive options.
Aetna’s clinical policy bulletins help guide evidence-based medicine that improves quality, reduces waste and provides members with access to affordable care.