Connecticut Clinical Review Criteria

Information regarding the specific criteria applied to an adverse determination is included in the notice sent at the time of the decision. We send
this notice to the customer and to the attending /ordering provider or the facility rendering the service.

We base our decisions regarding medical necessity, experimental or investigational treatment, or similar exclusion or limit on the following
sources or criteria:

Internal Review Criteria

Aetna Clinical Policy Bulletins Diagonal Arrow

See instructions below to access this information.

- OR -

External Sources for Review Criteria

MCG Health, LLC Diagonal Arrow

To access the MCG criteria used in your adverse determination, the following information is needed from your letter.
    • Date of letter
    • Claimant last name
    • MCG guideline code (as indicated in the letter)
    • Password (as indicated in the letter)

Utilization Reviews for the treatment of a substance use disorder are based on:

Utilization Reviews for the treatment of a child or adolescent mental disorder are based on:

Utilization Reviews for the treatment of an adult mental disorder are based on:

To access Aetna Clinical Policy Bulletins -

When our determination was based on a Clinical Policy Bulletin (CPB), you may use the link above to access the bulletin online.
  1. Refer to the Clinical Criteria field at the top of your letter for the specific bulletin number.
  2. Access the website by clicking on the link above, or copy this link and paste it into your browser.
  3. On the Clinical Policy Bulletins page, click the underlined link Medical Clinical Policy Bulletins.
  4. You may be asked to read and accept the terms and conditions associated with this section of the website.
  5. The Medical clinical policy bulletin Main page displays.
    • The page includes information about the use and development of the clinical policy bulletins
    • On this page, scroll down to the box titled Search Medical Clinical Policy Bulletins. Below this box, click on the link to the Numerical List.
  6. On the Numerical List page, click the link to the number range needed or scroll down the screen to find the link to the specific bulletin referenced in your letter.

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