Why Aetna Denies Chemotherapy / Infusion Therapy
Regimen not first-line per NCCN guidelines
Off-label use without compendia support
Continuation after disease progression not justified
Know Aetna's Criteria
Aetna uses their own Clinical Policy Bulletins (CPBs) and InterQual criteria. CPBs are publicly available and numbered.
Key policies to know:
- Clinical Policy Bulletins (CPBs) are publicly available and numbered
- Uses eviCore for radiology and cardiology prior auth
- Known for detailed, evidence-based CPBs with specific criteria
- Precertification list updated annually
Building Your Medical Necessity Argument
Cite specific NCCN guideline category and recommendation level
Document prior treatment lines and responses
Reference tumor molecular markers guiding treatment selection
If off-label, cite peer-reviewed evidence or compendia listing
P2P Call Tips for Aetna
Reference the specific CPB number and criteria being met
Aetna CPBs are very detailed -- read them before the call
Address each specific criterion in the CPB during the P2P
Aetna medical directors are typically receptive to guideline-based arguments
Guidelines to Reference
- NCCN Clinical Practice Guidelines by cancer type
- CMS Anticancer Chemotherapy NCD
Relevant CPT Codes
Specialty: Oncology
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