Applicable CPT / HCPCS / ICD-10 Codes Background References Policy Scope of Policy This Clinical Policy Bulletin addresses hypoxic ischemic encephalopathy. Medical Necessity Aetna considers total body cooling (TBC, also known as whole-body cooling) and/or selective head cooling (SHC) medically necessa...
call (866) 752-7021 or fax (888) 267-3277. For Statement of Medical Necessity (SMN) precertification forms, seeSpecialty Pharmacy Precertification.
Medical necessity review of infertility drugs by Aetna Specialty Pharmacy Guideline Management may be bypassed for infertility ART drugs that are for use with infertility medical procedures if the infertility procedure has been approved for coverage under the member’s Aetna medical benefit plan. During...
For the prostate cancer indication only, precertification of gonadotropin-releasing hormone products (also called luteinizing hormone-releasing hormone agents) is required of all Aetna participating providers and members in applicable plan designs. For precertification of these products for prostate cancer, ...
(6 ng/dL) if reference ranges are not available). Two consecutive fasting total serum testosterone levels are required to determine medical necessity of testosterone replacement, or 2 consecutive free or bioavailable fasting serum testosterone levels if total testosterone is in the low normal range. ...