Aetna Coverage Criteria
Latest Aetna coverage criteria updates25
- Coverage CriteriaClinical/Medical PolicyEff. 2021-12-01Site of Care requirement for advanced radiology imaging (MR and CT)Defines medical necessity criteria requiring advanced imaging (MRI and CT) performed in hospital outpatient settings to meet specific factors for authorization under Aetna's Enhanced Clinical Review; affects fully insured commercial members and providers seeking authorization.All Aetna updates
- Coverage CriteriaClinical/Medical PolicyEff. 2009-08-14Extended OphthalmoscopyPolicy governing medical necessity, coverage, and documentation requirements for extended ophthalmoscopy (detailed retinal drawing with interpretation) for evaluation of the posterior segment of the eye; applies to Aetna members and providers submitting claims to Aetna.All Aetna updates
- Coverage CriteriaClinical/Medical PolicyEff. 2009-07-24Cardiac Devices and Procedures for Occlusion of the Left Atrial AppendageDefines Aetna's medical necessity, experimental/investigational exclusions, provider and site requirements, and coding guidance for left atrial appendage closure (LAAC) devices and procedures in patients with non-valvular atrial fibrillation.All Aetna updates
- Coverage CriteriaClinical/Medical PolicyEff. 2009-06-19Comparative Genomic Hybridization (CGH)Coverage criteria and medical necessity guidance for use of comparative genomic hybridization (CGH)/chromosomal microarray analysis for prenatal and pediatric genetic evaluation, and certain dermatologic indications; applies to Aetna members and providers.All Aetna updates
- Coverage CriteriaClinical/Medical PolicyEff. 2009-06-19Peripheral Vascular StentsDefines Aetna's coverage stance and medical necessity criteria for peripheral arterial and venous stent placement, and identifies experimental/investigational uses; applies to Aetna members and participating providers following eviCore Peripheral Vascular Intervention Clinical Guidelines.All Aetna updates
- Coverage CriteriaClinical/Medical PolicyEff. 2009-04-10Hereditary AngioedemaDefines Aetna's medical necessity, precertification, and coverage criteria for prophylactic and acute pharmacologic treatments for hereditary angioedema (HAE) for commercial medical plans and specifies site-of-care considerations for certain agents.All Aetna updates
- Coverage CriteriaClinical/Medical PolicyEff. 2009-03-20PlerixaforDefines medical necessity criteria, dosing information, coding, and background evidence for plerixafor (Mozobil or generic) used to mobilize hematopoietic stem cells prior to autologous transplantation, primarily affecting clinicians and billing staff managing patients with non-Hodgkin lymphoma or multiple myeloma.All Aetna updates
- Coverage CriteriaClinical/Medical PolicyEff. 2009-03-20Robotic-assisted Rehabilitation of the ExtremitiesThis policy governs Aetna's coverage stance for robotic-assisted rehabilitation interventions and devices for upper and lower extremities, specifying which indications and devices are considered experimental/investigational and noting related policy cross-references. It affects providers submitting claims and prior authorization requests to Aetna.All Aetna updates
- Coverage CriteriaClinical/Medical PolicyEff. 2008-11-07Romiplostim (Nplate) coverageThis policy governs Aetna commercial medical plan coverage and medical necessity criteria for romiplostim (Nplate) across specified indications (ITP, HS-ARS, MDS, chemotherapy-induced thrombocytopenia) and prescriber requirements.All Aetna updates
- Coverage CriteriaClinical/Medical PolicyEff. 2008-10-10Age-Related Macular DegenerationDefines Aetna's medical necessity criteria for therapies used to manage neovascular (wet) ARMD and specific coverage criteria for the implantable miniature telescope (IMT) in patients aged 65 and older; lists interventions considered experimental/investigational and associated billing codes within the portion of the policy provided.All Aetna updates
- Coverage CriteriaClinical/Medical PolicyEff. 2008-08-08Certolizumab Pegol (Cimzia)Defines Aetna commercial medical plan precertification, prescribing, and medical necessity criteria for certolizumab pegol (Cimzia) for rheumatologic, dermatologic, and gastroenterologic indications and continuation of therapy.All Aetna updates
- Coverage CriteriaClinical/Medical PolicyEff. 2008-08-08Repository Corticotropin Injection (Acthar Gel and Purified Cortrophin Gel)Defines Aetna's coverage stance, precertification and clinical criteria for repository corticotropin injections (Acthar Gel and Purified Cortrophin Gel) for commercial medical plans, including FDA‑approved infantile spasms indication and other indications considered not medically necessary or experimental.All Aetna updates
- Coverage CriteriaClinical/Medical PolicyEff. 2008-03-07Panitumumab (Vectibix)This policy governs medical necessity, precertification, and coverage criteria for panitumumab (Vectibix) in commercial Aetna medical plans, primarily addressing use in colorectal cancer and related testing requirements.All Aetna updates
- Coverage CriteriaClinical/Medical PolicyEff. 2008-02-08Transanal Endoscopic MicrosurgeryThis policy governs medical necessity and coverage of transanal endoscopic microsurgery (TEM) for members covered by Aetna, specifying indications considered medically necessary and those considered experimental/investigational.All Aetna updates
- Coverage CriteriaClinical/Medical PolicyEff. 2007-12-14Spinal Surgery: Laminectomy and FusionMedical necessity criteria and coverage guidance for cervical, thoracic, lumbar and sacral laminectomy, laminoplasty and spinal fusion procedures for Aetna members.All Aetna updates
- Coverage CriteriaClinical/Medical PolicyEff. 2007-12-14Spinal Surgery: Laminectomy and FusionMedical necessity criteria and coverage guidance for cervical, thoracic, lumbar, sacral laminectomy and spinal fusion procedures for Aetna members, including indications, prerequisites, and select procedural notes affecting authorization and reimbursement.All Aetna updates
- Coverage CriteriaClinical/Medical PolicyEff. 2007-10-05Double Balloon EnteroscopyClinical policy governing when double balloon enteroscopy is considered medically necessary or investigational for Aetna members; applies to evaluation and treatment of small bowel conditions and certain related indications.All Aetna updates
- Coverage CriteriaClinical/Medical PolicyEff. 2006-11-17Home Behavioral Healthcare ServicesDefines clinical coverage and medical necessity criteria for skilled behavioral health services delivered in the member's home under Aetna benefits, and lists applicable billing codes and ICD-10 categories.All Aetna updates
- Coverage CriteriaClinical/Medical PolicyEff. 2006-10-13Barrett's EsophagusDefines Aetna's medical necessity, investigational/experimental stance, and coding guidance for treatments and diagnostics related to Barrett's esophagus; applies to Aetna members and treating providers.All Aetna updates
- Coverage CriteriaClinical/Medical PolicyEff. 2006-06-09Antiemetic TherapyClinical policy governing intravenous and selected injectable antiemetic therapies for prevention and treatment of nausea and vomiting related to cancer chemotherapy, radiotherapy, postoperative settings, pregnancy, and other refractory indications; applicable to Aetna-covered members and providers submitting claims for these interventions.All Aetna updates
- Coverage CriteriaClinical/Medical PolicyEff. 2006-04-04Transforaminal Epidural InjectionsCoverage and medical necessity criteria for diagnostic and therapeutic transforaminal epidural steroid injections (TFESIs), including limits on frequency, levels treated, guidance requirements, and investigational indications; applies to Aetna members/providers.All Aetna updates
- Coverage CriteriaClinical/Medical PolicyEff. 2006-01-31Prostate BiopsyCoverage policy for various prostate biopsy approaches (transperineal stereotactic template-guided saturation, transrectal ultrasound-guided, MRI-guided, and others) describing medical necessity, investigational procedures, coding guidance, and limitations for Aetna members and providers.All Aetna updates
- Coverage CriteriaClinical/Medical PolicyEff. 2005-03-15Vascular Endothelial Growth Factor Inhibitors for Ocular IndicationsThis policy governs medical necessity, precertification, and coverage criteria for vascular endothelial growth factor (VEGF) inhibitor injections for ocular indications under Aetna commercial medical plans, and identifies required prescriber specialties and continuation criteria.All Aetna updates
- Coverage CriteriaClinical/Medical PolicyEff. 2004-08-13Ocular PhotoscreeningDefines Aetna's medical necessity and investigational positions for ocular photoscreening and retinal birefringence scanning for detection of amblyogenic risk factors and strabismus in pediatric populations; lists applicable CPT/HCPCS and ICD-10 codes and summarizes evidence/background.All Aetna updates
- Coverage CriteriaClinical/Medical PolicyEff. 2004-04-13Cetuximab (Erbitux)Defines Aetna's medical necessity, precertification, and coverage criteria for cetuximab (Erbitux) for commercial medical plans, including approved disease indications, continuation criteria, and investigational uses.All Aetna updates
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Search Aetna coverage criteria and medical necessity requirements across 21,000+ policies from 170+ payers.
Search a drug (“Wegovy”), a procedure (“knee replacement”), or a policy name, then filter by payer, specialty, policy type, or effective year. Or start from the largest publishers: UnitedHealthcare coverage criteria and Cigna coverage criteria.
Each result links the full policy page, which lists the clinical requirements, covered codes, and effective dates from the source document.
Pair a criteria search with the prior authorization lookup for approval requirements, the timely filing lookup for claim deadlines, the live policy updates feed for the newest payer publications, and payer profiles for contacts and coverage context.
FAQ
Coverage criteria are the specific clinical requirements a payer sets for covering a drug, procedure, or service: diagnoses, symptom duration, prior treatments tried, age limits, and documentation. They are published inside medical policies and clinical criteria documents, and a claim or authorization that does not meet them is denied as not medically necessary.
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