Clinical Policy Process. James D. Cross, M.D. National Head Medical Policy and Program Administration Aetna, Inc. Overview. We will discuss the following issues: The purposes and goals of clinical policy at Aetna The criteria Aetna uses to evaluate medical technologies and treatments
Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.
James D. Cross, M.D.
Medical Policy and Program Administration
We will discuss the following issues:
The following criteria are considered in evaluating a medical technology:
Medically necessary is defined as:
A technology is deemed experimental and investigational if:
The following are exceptions to Aetna’s exclusion of coverage of experimental and investigational technologies:
These factors are considered in prioritizing requests for developing CPBs:
The Clinical Policy Unit conducts a comprehensive search of the peer-reviewed published medical literature:
Each new CPB and CPB revision is reviewed for potential cost impact:
Aetna’s Specialty Society Policy Liaison Group meets monthly to identify issues for medical specialty society input
We take all of these processes into consideration as we review new technologies and equipment
Here are examples of medical devices that have been considered by Aetna’s Clinical Policy Council