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The criteria used by Aetna’s Patient Management staff when rendering Utilization Management precertification, inpatient review, and retrospect review decisions can be found in Aetna’s Policy Bulletins and Guidelines for Determining Coverage.  A copy of the criteria upon which a specific determination was based can be obtained by calling Aetna’s Provider Service Center at 1-888-MDAetna (1-888-632-3862).

Aetna’s Clinical Policy Bulletins and Pharmacy Clinical Policy Bulletins explain and guide Aetna’s determination of whether certain services, medications or supplies are medically necessary, experimental and investigational or cosmetic.  Pharmacy Clinical Policy Bulletin can be requested by calling Aetna’s Pharmacy Management at 1-800-670-3566.

Aetna medical directors are available 24 hours a day for specific utilization management issues.  Physicians can contact Aetna’s Patient Management and Precertification staff at the telephone number on the member’s ID card.

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