Why Aetna Denies Home Health Services
Patient is not homebound
Skilled need not documented
Services exceed reasonable frequency
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 homebound status with specific functional limitations
Define the skilled need (wound care, medication management, PT/OT)
Note why outpatient services are not feasible
Reference recent hospitalization or change in condition
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
- CMS Home Health Coverage Requirements
- Medicare Benefit Policy Manual Ch. 7
Relevant CPT Codes
Specialty: Internal Medicine / Family Medicine
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