Why Aetna Denies Knee Arthroscopy
Degenerative meniscal tear in patient over 40
Conservative therapy not exhausted
Imaging does not support mechanical symptoms
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 mechanical symptoms (locking, catching, giving way)
Distinguish traumatic from degenerative tear
Note failure of 3+ months conservative management
Reference MRI findings showing displaced meniscal fragment
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
- AAOS Clinical Practice Guidelines for Knee Arthroscopy
- AIM Specialty Health MSK Guidelines
Relevant CPT Codes
Specialty: Orthopedics
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