Aetna Wisconsin Issues New Preapproval Requirements for Members

August 2019 ~

Effective July 1, Aetna Wisconsin will require prior authorization for certain procedures under its Enhanced Clinical Review Program with eviCore healthcare. According to the insurer, these changes will impact members in Medicare Advantage HMO/PPO Aetna^® products.

The requested services are reviewed in accordance with applicable Medicare National Coverage Determinations and Local Coverage Determinations, nationally recognized clinical and billing guidelines of the American College of Radiology (ACR), guidelines from other recognized medical societies, any state regulations or mandates, and Aetna’s Clinical Policy Bulletins (CPBs). Before services are performed, eviCore healthcare’s board-certified physicians will review authorization requests for medical necessity.

The following procedures will now require prior authorization under Aetna’s Enhanced Clinical Review Program:

• High-tech outpatient diagnostic imaging procedures such as MRI/MRA, nuclear cardiology, and PET scan and CT scan, including CTA
• Non-emergent outpatient stress echocardiography
• Non-emergent outpatient diagnostic left and right heart catheterization
• Insertion, removal and upgrade of elective implantable cardioverter defibrillator, cardiac resynchronization therapy defibrillator and implantable pacemaker
• Polysomnography (attended sleep studies)
• Interventional pain management
• Musculoskeletal large joint (hip and knee) arthroplasty procedures

The following services do not require preapproval:

• Inpatient radiology
• Emergency room radiology
• Outpatient radiology (other than those services listed above)

Aetna recommends that ordering physicians get authorizations and share the approval numbers with the facility performing the procedure when it is scheduled.

EviCore healthcare will fax its approval decision to the ordering physicians and requested facilities. Approvals have authorization numbers and one or more CPT^® codes specific to the approved services. If the requested service is different from what eviCore healthcare approves, the facility must contact eviCore healthcare for review and approval before submitting claims. If services are performed without approval, payment may denied. Coverage is determined in accordance with the policy’s terms and conditions and with the insurer’s policies and procedures.

NOTE: for cases involving members in need services in less than 48 hours due to medically urgent conditions, call eviCore healthcare for fast review and identify that the request is for medically urgent care.

To review past CPBs, visit Aetna’s Helpful Links page.

For a complete list of procedures requiring an authorization, visit eviCore healthcare.

CPT^® is a registered trademark of the American Medical Association.

Source(s): Aetna OfficeLink Updates, June 2019;