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 2020 Immunization Schedule: Adult and Child

CDC ACIP Vaccine Recommendations

 

Adult Preventive Screenings

US Preventive Services Task Force (USPSTF)

Asthma

National Heart, Lung and Blood Institute (NHLBI)-Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma (EPR-3) Published Aug 2007

Alcohol Abuse

National Institute on Alcohol Abuse and Alcoholism (NIAAA), Professional Education Materials (gateway)**

ADHD

American Academy of Pediatrics (AAP): ADHD: Clinical Practice Guideline for the Diagnosis, Evaluation and Treatment of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents, October 2019

Cancer Screenings

American Cancer Society Guidelines for the Early Detection of Cancer

Chronic Obstructive Lung Disease (COPD)

Global Initiative for Chronic Obstructive Lung Disease 2019 Report

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)

2013 ACCF/AHA – Guideline for the Management of Heart Failure

 

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

Coronary Artery Disease

2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease

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

Management of Major Depressive Disorder (MDD) (2016)

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

Diabetes

American Diabetes Association: Diabetes Care (2015)

2020 American Diabetes Association (ADA) Standards of Medical Care in Diabetes

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)

Hypertension (HTN)

Guidelines for Management of High Blood Pressure in Adults

Guidelines Made Simple|2017 Guideline for the Prevention, Detection, Evaluation and Management of High Blood Pressure in Adults

Long Term Care

CDC: Nursing Homes and Assisted Living (infection control and other issues)

Medication Management

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

Opioids for Chronic Pain

CDC Guideline for Prescribing Opioids for Chronic Pain- United States, 2016

Pediatric Preventive Guidelines

ACIP Recommended Immunization Schedule for Children and Adolescents

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

Prenatal Services

Prenatal Care, American Family Physician

ACOG’s Clinical Guidelines Related to Deliveries before 39 weeks

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

May require ACOG membership to access:

ACOG: Optimizing Postpartum Care*

Substance Use

SAMHSA: Behavioral Health Treatments and Services

Tobacco Cessation

CDC: Tobacco Cessation Fact Sheet