Why Aetna Denies Colonoscopy
Screening interval not met
Prior authorization not obtained
Age does not meet screening criteria
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
Distinguish diagnostic from screening indication
Document symptoms warranting diagnostic colonoscopy
Reference family history or personal risk factors
Note positive screening test (FIT, Cologuard) requiring follow-up
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
- USPSTF Colorectal Cancer Screening Recommendations
- AGA Guidelines for Colonoscopy Surveillance
- NCCN High-Risk Screening Guidelines
Relevant CPT Codes
Specialty: Gastroenterology
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