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How we make coverage decisions

February 02, 2018 | Primary Care

Whenever we tell members that a requested treatment is not covered, they want to know – how could we deny a procedure that their doctor believes could improve their quality of life? Our answer is based on scientific data – or lack thereof – and our responsibility to put member safety first.

It is never easy to tell an individual or family that a treatment or procedure is not approved – it’s the hardest thing we have to do. However, our guiding principles will continue to be proven effectiveness and member safety, as determined by rigorous scientific studies.

Only if effectiveness and safety are equivalent will we consider the relative cost-effectiveness of various treatments. In certain cases, we require a particular therapy to be tried before covering comparable, but more expensive options.

A member’s benefit plan defines the services that are covered and excluded. Our professional clinical staff develops clinical policy bulletins to inform members and providers which treatments are considered experimental and investigational, as well as the criteria that determine whether a technology or service is medically necessary. We use these bulletins to guide medical coverage decisions. Clinical policy bulletins do not guarantee coverage, but rather define when a service or treatment will be approved if it is not specifically excluded by the member’s plan.

Aetna’s clinical policy bulletins help guide evidence-based medicine that improves quality, reduces waste and provides members with access to affordable care. We constantly evaluate new published and peer-reviewed studies or additional evidence when developing our clinical policies, and will continue to do so.

For more information, please visit the clinical bulletins page or read the FAQ.