Why Aetna Denies CT Abdomen and Pelvis
Prior imaging not performed first (ultrasound, X-ray)
Diagnosis does not support advanced imaging
Duplicate study within short timeframe
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
Document why less invasive imaging is insufficient
Note acute clinical findings requiring CT
Reference abnormal lab values or physical exam findings
Cite clinical suspicion for specific pathology (abscess, mass, obstruction)
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
- ACR Appropriateness Criteria
- Choosing Wisely Recommendations for Abdominal Imaging
Relevant CPT Codes
Specialty: Internal Medicine / Emergency Medicine
Want the full strategy?
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