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Precertification list* Precert exceptions Applies to: Aetna Choice®, Aetna Choice® POS II, Aetna MedicareSM Plan (PPO), Aetna MedicareSM Plan (HMO), Aetna Medicare Dual AdvantageSM Plan (HMO), all Aetna HealthFund® products, Aetna Health Network OnlySM, Aetna Health Network OptionSM, Aetna Open Access® Elect Choice®, Aetna Open Access® HMO, Aetna Open Access® Managed Choice®, Open Access Aetna SelectSM, Elect Choice®, HMO, Managed Choice® POS, Open Choice®, Quality Point-of-Service® (QPOS®) and Aetna SelectSM benefits plans and all products that may include the Aexcel® networks and include the designation Aexcel or Aexcel Plus®** 1. Inpatient confinements S  urgical and non-surgical >ncluding vaginal or Cesarean i deliveries excluding routine delivery *** ■  killed nursing facility S ■  ehabilitation facility R ■  npatient hospice (except Medicare) I 2.  econstructive procedures that R may be considered cosmetic ■ ■ B  lepharoplasty/canthopexy/ canthoplasty ■  reast reconstruction/breast B enlargement ■  reast reduction/mammoplasty B ■  ervicoplasty C ■  hemical peels C ■  xcision of excessive skin due E to weight loss ■  astroplasty/gastric bypass G ■  air transplant H ■  njection of filling material I ■  ntersex surgery I ■  ipectomy or excess fat removal L ■  toplasty O ■  ectus excavatum repair P ■  hinoplasty/rhytidectomy R ■  urgical treatment of gynecomastia S ■ S  clerotherapy or surgery for varicose veins 4. Lumbar spinal fusion surgery  5. Uvulopalatopharyngoplasty,  including laser-assisted procedures 6. Orthognathic surgery procedures,  bone grafts, osteotomies and surgical management of the temporomandibular joint 7. Dental implants and oral appliances 10.  Medical injectables ■ ® ® ® ® ® ® 9. The following conditionally  eligible services† A  lpha 1-proteinase inhibitor — human ■  utologous Chondrocyte A Implantation, Carticel® ■  otox injections — botulinum toxin B type A ■  ochlear device and/or implantation C ■  ognitive skills development C ■  orsal Column (lumbar) D Neurostimulators: Trial or Implantation Blood-clotting factors Growth hormone ■  nterferons when used for I hepatitis C > Pegasys > Peg Intron > Rebetron > Roferon A > Intron A > Infergen ■  ntravenous immunoglobulin I (IVIG) ■ 8. Elective (non-emergent)  transportation by ambulance or medical van, and all transfers via air ambulance G  I tract imaging through capsule endoscopy ■  igh-frequency chest wall H oscillation generator system ■  yperbaric oxygen therapy H ■  nco Type DX O ■  sseointegrated implant O ■  steochondral allograft/knee O ■  tereotactic radiosurgery S ■  omatosensory evoked S potential studies ■ 3.  rtificial intervertebral disc surgery A ■ * he term precertification here means the utilization review process to determine whether the T requested service, procedure, prescription drug, or medical device meets the company’s clinical criteria for coverage. It does not mean precertification as defined by Texas law, as a reliable representation of payment of care or services to fully insured HMO and PPO members. ** ot all plans are offered in all service areas. Precertification is required when Aetna is secondary N payer. *** total length of stay of 3 days or less for vaginal deliveries. A total length of stay of 5 days or A less for a cesarean section. † ll services deemed “never effective” are excluded from coverage. Aetna defines a service as A “never effective” when it is not recognized according to professional standards of safety and effectiveness in the United States for diagnosis, care or treatment. Visit the secure website, available through www.aetna.com, for more information. Select “Claims,” “CPT/HCPCS Coding Tool,” “Clinical Policy Code Lookup.” 23.03.858.1 D (10/09) Please see the Exceptions to Aetna Precert List box on the bottom of this page.  ■ F  or the following services, call 1-866-503-0857 or fax applicable request forms to 1-888-267-3277 > Acthar Gel > Erbitux >  rythropoesis Stimulating Agents E (ESA), such as darbepoetin alpha (Aranesp), epoetin alpha (Epogen and Procrit) and epoetin beta (Micera) R >  ituxan when used for Rheumatoid Arthritis > Synagis > Xolair > Vectibix ® transplant evaluations and transplants including, but not limited to, kidney, liver, heart, lung and pancreas, and bone marrow replacement or stem cell transfer after high-dose chemotherapy ® ■ ® ■ ■ ■ L  imb prosthetics C  ustomized braces E  lectric or motorized wheelchairs and scooters 13. n-network level of benefits for I nonparticipating physicians and providers for non-emergent services,†† only when there is an identified network deficiency. (This category does not apply to Open Choice members.) 14. Special programs ■ ■ ■ ■ ■ B  eginning Right® maternity program, including genetic testing, antenatal testing, perinatal consultations and counseling: 1-800-272-3531 B  RCA genetic testing: 1-877-794-8720 I  nfertility Program: 1-800-575-5999 ® N  ational Medical Excellence Program : 1-877-212-8811 for all major organ P  ediatric Congenital Heart Surgery Program: see the member’s ID card to contact the Precertification unit ■ Connecticut: F >  or HMO and ACAS plan members: >  utpatient physical and O occupational therapy precertification through Orthonet at 1-800-771-3205 ■ Metro NY/NNJ: F >  or HMO-based plan members only: >  utpatient physical and O occupational therapy precertification through Orthonet at 1-800-771-3205 >  on-urgent outpatient diagnostic N left heart catheterizations and echo stress tests through CareCore >  -888-647-5940 for Northern 1 New Jersey members >  -888-622-7329 for NY 1 members S >  leep apnea study management — moving from facility-based study to homebased study — through CareCore National at 1-888-647-5940 prior to performing these tests ■ W  here applicable >  utpatient imaging precertification O for computed tomographic (CT) studies, coronary CT angiography, MRI/MRA, nuclear cardiology, nuclear medicine, PET scans through regional-specific †† ll A products that include Aetna HealthFund, Aexcel Plus products, Aetna Health Network Option products, Aetna Choice, Choice POS II, Aetna Medicare Plan (PPO), Open Access Managed Choice, QPOS and USAccess benefits plans may include the option for members to elect to go outside the network and receive reduced benefits. 23.03.858.1 D (10/09) ■ ©2009 Aetna Inc. F  or HMO-based plan members only: >  hiropractic therapy C precertification through regional-specific managed service organizations (American Chiropractic Network, American Specialty Health, Healthways Wholehealth Network and Triad) P  re-implantation genetic testing: 1-800-575-5999 >  or all members (with plans F applicable to this precert list): T  o precertify mental health or substance abuse services, see the member’s ID card. Here is a list of services requiring precertification. ■ 11.  ll home health care services, A including home uterine monitoring and home hospice 12.  elected durable medical S equipment Radiology Benefit Manager (MedSolutions or Care Core National) Additional Assistance and Information ■ E  lectronic submission of precert requests and inquiries is preferred. If you require assistance with precertification, please call our Aetna Voice Advantage line using the appropriate phone number indicated below and select the precertification option: ® >  or HMO-based benefits F plans, call 1-800-624-0756. >  or indemnity and PPO-based F benefits plans, call 1-888-632-3862. ■ ■ ■ ■ V  isit Clinical Policy Bulletins and DocFind . ® C  ontact Aetna Pharmacy Management at 1-800-414-2386 for precertification of oral medications only. C  all 1-866-782-2779 for information on injectable medications not listed. P  recertification approvals are valid for six months in all states unless otherwise indicated at the time of precertification.