Guidelines

Clinical Policy Bulletins

Clinical Policy Bulletins (CPBs) state Aetna’s policy regarding the medical necessity or investigational status of medical technologies and other services to aid in coverage decisions.  They are created by a national review team and are based on published medical literature, formal technology assessments and structured evidence reviews, evidence-based consensus statements, expert opinions and evidence-based guidelines from professional and public health entities. 

Clinical Practice Guidelines  

Clinical Practice Guidelines document best practices and recommendations for care, as determined by respected professional and public health organizations.   To help provide our members with consistent, high quality care that uses services and resources effectively, we provide links to a selection of guidelines for conditions and situations important to the health of our members.  Some of these are treatment protocols, while others document recommended preventive health measures.

These guidelines are intended to clarify standards and expectations. They should not:

  • Take precedence over your responsibility to provide treatment based on the member’s individual needs
  • Substitute as orders for treatment of a member
  • Guarantee coverage or payment for the type or level of care proposed or provided

Use these resources to find information about specific treatment types and guidelines.

Disease Management Condition

Guideline

Adult Preventive Care

CDC Immunization Schedule: Adult and child

CDC ACIP Vaccine Recommendations

 

Adult Preventive Screenings

US Preventive Services Task Force Preventive Screenings

Asthma

NIH Guidelines for Diagnosis and Management of Asthma (EPR-3)

Alcohol Abuse

How to Help Patients Who Drink Too Much: A Clinical Approach, 2005 Edition (NIAAA)

ADHD

American Academy of Pediatrics (AAP): Clinical Practice Guideline for the Diagnosis, Evaluation and Treatment of Attention-Deficit/Hyperactivity Disorder (ADHD) in Children and Adolescents, October 2011.

Cancer Screenings

American Cancer Society Guidelines for the Early Detection of Cancer

Chronic Obstructive Lung Disease (COPD)

Global Initiative for Chronic Obstructive Lung Disease: Global Strategy for the Diagnosis, Management and Prevention of COPD

Cognitive Impairment

National Institute on Aging: Assessing Cognitive Impairment in Older Patients: A Quick Guide for Primary Care Physicians

Community Reintegration

JAMA, 2011: The Effect of Guided Care Teams on the Use of Health Services

Congestive Heart Failure (CHF)

2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure

Coronary Artery Disease

2014 ACC/AHA/AATS/PCNA/SCAI/STS Focused Update of the Guideline for the Diagnosis and Management of Patients with Stable Ischemic Heart Disease

2015 ACC/AHA Focused Update of Secondary Prevention Lipid Performance Measures

AHA/ACC/HHS Strategies to Enhance Application of Clinical Practice Guidelines in Patients With Cardiovascular Disease and Comorbid Conditions

Dental Services

American Academy of Pediatrics: Children’s Oral Health (Gateway)

Depression

American Psychiatric Association (APA) Practice Guideline for the Treatment of Patients with Major Depressive Disorder, Third Edition.

Institute for Clinical Systems Improvement Health Care Guidelines: Depression in Primary Care

Diabetes

American Diabetes Association: Diabetes Care (2015)

American Diabetes Association (ADA) Standards of Medical Care in Diabetes- 2017

Elder Abuse

CDC: Elder Abuse: Risk and Protective Factors

Elderly and Disabled Information

National Institute on Aging (gateway)

HIV/AIDS

HRSA: Clinical Care Guidelines and Resources (HIV)

Home and Community Based Services

Home and Community Based Services Clearinghouse (gateway)

Home and Community Based Care: Intellectual Disabilities

Hypertension (HTN)

Guidelines for Management of High Blood Pressure in Adults

Long Term Care

CDC: Nursing Homes and Assisted Living (infection control)

Medication Management

Health Care Association of New Jersey: Medication Management Guideline (2013)  

Opioids for Chronic Pain

CDC Guideline for Prescribing Opioids for Chronic Pain

Pediatric Preventive Guidelines

ACIP Recommended Immunization Schedule for Children and Adolescents

Medicaid.gov: Early and Periodic Screening, Diagnostic and Treatment

Prenatal Services

American Family Physician: Prenatal Care Editor's Choice

ACOG’s Clinical Guidelines Related to Deliveries before 39 weeks

World Health Organization’s Postnatal Care of the Mother and Newborn

ACOG: Redefining the Postpartum Visit

Substance Use

SAMHSA: Behavioral Health Treatments and Services

Tobacco Cessation

CDC: Tobacco Cessation Fact Sheet