Why Aetna Denies Hysterectomy
Conservative management not exhausted (hormonal therapy, ablation)
Uterine size does not meet threshold
Alternative less invasive procedures not tried
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 failure of hormonal management
Note uterine size and symptom severity
Explain why less invasive alternatives are not appropriate
Reference impact on quality of life and functional status
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
- ACOG Practice Bulletin on Hysterectomy
- AAGL Practice Guidelines for Hysterectomy
Relevant CPT Codes
Specialty: Gynecology
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