TN Clinical 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:

Medical Clinical Criteria


Aetna Clinical Policy Bulletins


http://www.aetna.com/healthcare-professionals/policies-guidelines/clinical_policy_bulletins.html  

See instructions below to access this information.

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 link for 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 CPBs. 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.

MCG Health, LLC 


MCG Health, LLC clinical criteria is proprietary.  A copy of the clinical criteria used in making the adverse determination will be made available upon request.