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CVS Health’s Aetna division is another major insurer providing coverage for detox, rehab, outpatient programs, and MAT. Aetna’s approach to medical necessity for substance abuse treatment is guided by a combination of Aetna’s Clinical Policy Bulletins, MCG Care Guidelines, and the ASAM Criteria. In fact, Aetna explicitly lists the ASAM Criteria, 3rd Edition among the nationally recognized guidelines it uses for coverage decisions (Utilization Management | Aetna). Providers working with Aetna should be prepared to navigate Aetna’s precertification (preauthorization) requirements, ensure documentation aligns with ASAM dimensions, and use correct billing codes (Aetna has specific precertification lists for certain CPT/HCPCS codes (Everything You Ever Wanted to Know About Aetna Precertification for Addiction Treatment Billing)). Below is a comprehensive breakdown for Aetna:
Medical Necessity Guidelines and ASAM Alignment for Aetna
Aetna maintains Clinical Policy Bulletins (CPBs) that outline coverage rules for various treatments. For SUD treatment, Aetna doesn’t have a single CPB that lists detailed criteria (unlike some insurers’ medical policies), but they rely on ASAM placement criteria and MCG (formerly Milliman) Behavioral Health Guidelines to adjudicate requests. On Aetna’s utilization management page, they state coverage decisions are based on MCG™ guidelines and the ASAM Criteria for addictive conditions (Utilization Management | Aetna) (Precertification – Health Care Professionals | Aetna). This means if you present a case meeting ASAM’s standards for a given level, you’re generally in safe territory.
However, Aetna’s internal terminology might differ slightly. Aetna uses a proprietary tool called LOCAT (Level of Care Assessment Tool) which aids their clinicians in matching patients to levels of care ([DOC] GENERAL GUIDELINES - Aetna). LOCAT likely incorporates ASAM-like questions. In practical terms, as a provider, you should focus on documenting the patient’s needs per ASAM’s six assessment dimensions and indicating the corresponding level of care (e.g., ASAM 3.7 for inpatient rehab).
Notably, Aetna’s behavioral health arm (now under Evernorth, formerly part of Cigna due to a partnership) might also reference Evernorth Behavioral Medical Necessity Criteria in some cases. But Aetna’s publicly facing info emphasizes ASAM. In fact, Aetna provides a patient brochure on ASAM to educate members about how care decisions are made (asam-criteria) (asam-criteria).
Detoxification (Withdrawal Management) – Aetna Criteria
For inpatient detox, Aetna will approve coverage when the member is at risk of moderate to severe withdrawal that requires medical management. Indications include: history of severe withdrawal (DTs, seizures), current signs of significant withdrawal (e.g., tachycardia, elevated blood pressure, confusion), use of substances with potentially dangerous withdrawals (alcohol, benzodiazepines), or polysubstance withdrawal with medical complications. Aetna’s criteria (via MCG/ASAM) would typically say any withdrawal that cannot be safely managed in a less intensive setting qualifies for inpatient.
Example: An alcohol-dependent patient with a CIWA of 15+ and comorbid hypertension should meet criteria for inpatient detox under Aetna’s guidelines. Document vital signs and any delirium/agitation. If the patient has a positive BAL on admission, note that as well, but the key is the expected withdrawal course.
For opioid withdrawal, while not life-threatening, inpatient detox might be warranted if there are complicating factors (failed outpatient buprenorphine tapers, pregnancy, or serious psychiatric instability).
Aetna also covers ambulatory detox (outpatient withdrawal management) in appropriate cases. In fact, due to legislation, starting in 2019 Aetna had to remove preauthorization requirements for outpatient detox (ambulatory withdrawal) in some markets (Everything You Ever Wanted to Know About Aetna Precertification for Addiction Treatment Billing). That suggests they encourage less restrictive care when safe. So if you propose outpatient detox, demonstrate patient reliability and a solid plan (e.g., daily buprenorphine induction visits or a 5-day Librium taper with daily nursing check-ins). Aetna might not even require prior auth for ambulatory detox due to those law changes.
Billing for detox with Aetna:
Use H0010/H0011 for inpatient detox (Aetna’s precertification list includes these for inpatient admissions (Everything You Ever Wanted to Know About Aetna Precertification for Addiction Treatment Billing)).
For hospital-based detox, if billed under medical, it might use revenue code 012x and be covered under the behavioral health benefit anyway.
H0014 for ambulatory detox should be covered and notably, per Aetna’s 2019 policy change, no precert needed for H0014 (ambulatory detox) for in-network providers (Everything You Ever Wanted to Know About Aetna Precertification for Addiction Treatment Billing). Always verify if that applies in your state.
If you’re just billing E/M for outpatient management (like a series of office visits for a taper), those would fall under regular outpatient and not need auth.
Inpatient Residential Rehab – Aetna Criteria
Aetna’s “inpatient” substance abuse treatment can refer to either hospital-based rehab or non-hospital residential. Typically:
Inpatient (hospital) rehab is used for patients who need 24-hr care and have substantial medical or psychiatric needs requiring hospital resources. This is rarer; often patients go to residential rehab unless they have a co-occurring medical condition.
Residential rehab is a non-hospital 24-hour treatment setting focusing on SUD recovery.
Aetna’s criteria (drawing from ASAM Level 3.5/3.7) for residential treatment require evidence such as:
Imminent relapse risk: patient cannot stay sober outside a structured 24-hr setting (multiple relapses, inability to maintain abstinence even during IOP).
Lack of support: home environment is chaotic or encourages use (for instance, family members who use or an abusive situation).
Co-occurring needs: patient has psychological issues (depression, trauma) that are severe enough to need intensive therapy throughout the week, and they have not stabilized with outpatient treatment.
Recent treatment history: If the patient already tried intensive outpatient or had a recent inpatient stay and still needs more, that supports residential. Aetna often looks for a “failure at lower level” unless contraindicated. They won’t typically cover a jump straight to residential unless justified (e.g., patient drinking a fifth of liquor daily with suicidal ideation – you could argue they need residential directly after detox).
Aetna’s Clinical Policy Bulletin on Mental Health Parity ensures that they use comparable standards to med-surg. So if a patient meets an acute criteria analogous to a medical admission (like uncontrolled symptoms requiring 24-hr care), Aetna must cover. In other words, if the situation with SUD is as dangerous as, say, diabetic ketoacidosis is on the medical side (not medically, but in terms of risk and need for supervision), Aetna should approve inpatient SUD care.
One unique aspect: Aetna is quite data-driven. They might use proprietary algorithms that flag certain combinations (like if someone had multiple detox admissions in a short time, they may preemptively suggest residential). As a provider, mention patterns: “Patient has had 3 detox admissions in 6 months with no follow-up residential – indicating a pattern that necessitates inpatient rehab to break the cycle.”
Billing codes for inpatient/residential rehab (Aetna):
Aetna’s Behavioral Health Precertification List (accessible on their provider website) enumerates which codes/levels need precert. They explicitly mention that inpatient admissions (which would include rehab) and residential treatment center (RTC) admissions always require precertification (Everything You Ever Wanted to Know About Aetna Precertification for Addiction Treatment Billing).
Codes representing these services that Aetna highlighted include H0008, H0009, H0010, H0011, H0012, H0013, H0017, H0018, H0019 ((Everything You Ever Wanted to Know About Aetna Precertification for Addiction Treatment Billing). Essentially, any code for inpatient or residential rehab is on the precert list.
Use H0018/H0019 for non-hospital residential treatment days. Ensure that the claims align with the authorization (if 21 days authorized, don’t bill 28).
If it’s a hospital rehab, it might still bill with H0010/H0011 (some plans do that) or as a DRG. But since Aetna puts H0010/H0011 on their list, they expect those codes from providers.
Also note, Aetna sometimes requires the provider type to match the code – e.g., an RTC must be licensed appropriately. They might deny if a provider bills H0018 but isn’t credentialed as a residential facility in their network.
Partial Hospitalization (PHP) & Intensive Outpatient (IOP) – Aetna Criteria
Aetna uses the term “Partial Hospitalization Program (PHP)” for day-treatment level (often 5 days/week, ~6 hours/day) and “Intensive Outpatient Program (IOP)” for the multi-day shorter sessions. In Aetna documentation and precert lists:
Partial hospitalizations always require precert (Everything You Ever Wanted to Know About Aetna Precertification for Addiction Treatment Billing).
Historically, Aetna required precert for IOP too, but due to some law changes, from 2019 onward, Aetna had to stop requiring preauthorization for IOP in certain jurisdictions (Everything You Ever Wanted to Know About Aetna Precertification for Addiction Treatment Billing). This was likely due to state parity enforcement or settlement agreements (some states pressed insurers to remove PA for routine outpatient SUD above a certain threshold).
Check Aetna’s current precert rules: According to their 2022 guidance, IOP was removed from precert in some states, but to be safe, many providers still obtain an authorization number for IOP services especially if the plan is employer-based (those might still have PA requirements).
Criteria:
For PHP, Aetna wants to see severe symptoms that need near-daily monitoring but not 24-hour. For example, persistent suicidal ideation now under control but requiring daily therapy and medical check, or a patient with stimulant use disorder and co-occurring bipolar where daily structure prevents relapse.
IOP criteria with Aetna are akin to ASAM Level 2.1: patient has ongoing substance use or high risk thereof that hasn’t been controlled with weekly therapy, needs a structured program 3+ days/week, but is medically stable and has a safe living environment. Aetna might require that the patient is abstinent upon entering IOP or concurrently enrolled in a detox/maintenance regimen if not abstinent (some IOPs accept people still using; Aetna may question that unless it’s an MAT program).
Aetna often expects that IOP is a step-down from PHP or residential, or a step-up from routine outpatient. Document if the patient is stepping down (“Just completed 14-day inpatient, now needs IOP to continue progress”) or stepping up (“Patient failed weekly therapy, now entering IOP”).
Also, Aetna may limit coverage of IOP/PHP to certain provider types. For instance, an IOP run by a licensed facility is covered, but if an uncredentialed provider tries to bill IOP codes, claims will be denied. So ensure your facility is in-network for those services.
Billing codes for PHP/IOP (Aetna):
For PHP, Aetna commonly uses HCPCS S0201 (which is on their precert list for PHP). This code represents a daily PHP bundle. Alternatively, they might accept Rev Code 912 with CPT 90791 once per day – it depends on contracting. But S0201 is a good bet for non-hospital PHP programs.
For IOP, H0015 is the primary code. Aetna in their documentation essentially equated IOP with certain CPT/HCPCS and noted that as of 2019 they no longer precert H0015 for in-network providers (Everything You Ever Wanted to Know About Aetna Precertification for Addiction Treatment Billing). That said, always confirm because out-of-network providers definitely need precert.
If billing professional claims for IOP (say a physician overseeing an IOP bills an E/M and therapy codes instead of H0015), that wouldn’t capture the IOP properly. It’s better for the facility to bill the H0015 per diem.
Aetna’s systems may also recognize S9480 for IOP, but their official list leans toward H0015. Check the Aetna Behavioral Health Precertification Code Search tool – one caveat, as noted in a BehaveHealth blog, Aetna’s public CPT code search tool is misleading for behavioral health, often saying “no precert needed” even when behavioral health policies do require it (Everything You Ever Wanted to Know About Aetna Precertification for Addiction Treatment Billing). So don’t rely on that blindly; refer to their precert list PDFs or call provider support.
Medication-Assisted Treatment (MAT) – Aetna Criteria
Aetna covers MAT for opioid and alcohol use disorders, and since CVS Health owns Aetna, they have made efforts to expand MAT access (CVS pharmacies, for example, stock naloxone etc., reflecting the corporate support for MAT).
Preauthorization for MAT medications: Aetna has largely removed PA requirements for buprenorphine products in line with recommendations. For instance, Aetna no longer requires prior auth for Suboxone for most commercial plans up to certain quantities. They have quantity limits (like 16mg or 24mg per day max without auth). Methadone for OUD doesn’t go through the pharmacy benefit, so not applicable for PA in the same way.
Criteria for MAT: Aetna expects a DSM-5 diagnosis of opioid use disorder (moderate or severe typically, but MAT can be used for mild if clinically justified) or alcohol use disorder for naltrexone, etc. They generally do not require failure of drug-free treatment first – Aetna knows MAT is first-line now. In some clinical policy bulletins, Aetna might mention that psychosocial support should accompany MAT, but they won’t deny MAT if therapy isn’t in place (parity NQTL rules prevent that).
Methadone: If a member is in an Opioid Treatment Program, Aetna often just pays via the OTP bundle (depending if the state Medicaid is Aetna or if commercial covers OTP – since historically OTPs were not covered by commercial insurance, but that’s changing). Medicare now covers OTP through bundled codes and some Aetna plans mirror that. Aetna’s provider manual indicates they follow all federal parity and will cover methadone maintenance when medically necessary – which for an OUD patient who prefers or needs methadone, it generally is.
Naltrexone (Vivitrol): Aetna usually covers it under medical benefit with no PA if the indication is clear. Providers should document that patient has been opioid-free 7-10 days before starting Vivitrol (for OUD) to meet safety guidelines.
One thing to highlight: in some Aetna plans, certain MAT services may require using particular billing codes or even carve-outs. For example, Aetna might require using the new HCPCS G-codes for OTP (G2067-G2075) if billing through medical benefit. Stay updated on their policies if you’re an OTP.
Billing codes for MAT (Aetna):
Buprenorphine/naloxone (Suboxone) – usually pharmacy benefit coverage. If prescribing, ensure the patient’s plan covers it (Aetna covers generic buprenorphine-naloxone widely; if brand needed, might require a medical exception). No specific billing by provider aside from office visits.
Office visits for MAT – use E/M codes with add-on HCPCS code H0050 if required by state (some Aetna Medicaid plans use H0050 to indicate “drug counseling and/or medication monitoring, per 15 minutes”). But in many Aetna plans, just billing standard E/M (99213 etc.) is fine.
Methadone (OTP) – Aetna may pay OTPs via H0020 or via the new Medicare OTP bundle codes (G2078 etc.). Since Aetna now has Medicare Advantage, they follow Medicare billing for OTP: weekly bundled payments that include medication + counseling. Check with Aetna if they credential OTPs directly. If yes, bill according to their instructions (for example, one MA plan might instruct to bill G2077 weekly).
Naltrexone (extended-release injectable) – bill J2315 (380 mg) and administration. Aetna might require a one-time auth for J2315 if the plan still has an old rule, but most have dropped it.
Naloxone kits – Covered under pharmacy benefit for patients; not really a provider billing item, but ensure patients can get them (Aetna usually covers without prior auth).
Counseling – Bill therapy codes normally. If part of an IOP or OTP, those may be bundled. Aetna encourages therapy with MAT but will reimburse separately if appropriate (for instance, a patient on buprenorphine seeing a therapist weekly would have therapy claims paid normally).
Aetna’s Precertification Process and Documentation Requirements
Aetna refers to prior authorization as “precertification” (or precert). They sometimes use the terms preauthorization, pre-certification, and prior approval interchangeably. For providers, the precert process with Aetna is critical for higher levels of care:
What requires precert? Aetna’s Behavioral Health Precertification List states that all inpatient, residential, and PHP admissions require precert, as do certain procedures like Transcranial Magnetic Stimulation (TMS) and Applied Behavioral Analysis (ABA) (Everything You Ever Wanted to Know About Aetna Precertification for Addiction Treatment Billing). As of 2019, IOP and outpatient detox were removed from the precert requirement in many plans due to regulation (Everything You Ever Wanted to Know About Aetna Precertification for Addiction Treatment Billing). But to be safe, check the member’s plan documents or call Aetna. Some self-funded (ERISA) plans may still “recommend” pre-notification for IOP.
How to precert: Providers or facilities can precertify by phone, fax, or via Aetna’s provider portal on Availity. Often the quickest way is calling the Aetna Behavioral Health precert line. Have all patient info and clinical data ready. Aetna will provide a precertification case number if approved.
Timing: Precertification should ideally be obtained before services start. Aetna allows retroactive requests, but if you start treatment without pre-cert and then request, you risk denial for lack of timely notification. The only exception is emergency admissions (e.g., patient presents to ER in withdrawal and is admitted to detox); in that case, notify Aetna within 24-48 hours of admission.
Info needed: Aetna will ask for demographic info and clinical specifics. Be prepared to provide: SUD diagnosis, substances used and last use, withdrawal symptoms, mental health symptoms, treatment history, current medications, support system, and why the requested level is appropriate. Essentially, cover ASAM Dimensions 1-6 succinctly.
Continued Stay Review: If a patient is in residential or inpatient, Aetna will usually authorize a set number of days (based on guidelines) and then require an update. For example, they might approve 7 days of inpatient rehab initially. On day 5, you should contact Aetna’s care manager with an update to get more days authorized. They’ll want to know the patient’s progress, current symptoms, any remaining withdrawal issues, participation level, and discharge plan.
Documenting medical necessity for Aetna: It’s crucial to explicitly document why each service is medically necessary in your clinical notes and in the info you send to Aetna. Use phrases from ASAM or Aetna’s criteria such as:
“Patient continues to experience cravings and psychological withdrawal symptoms that require structure beyond what could be managed in outpatient – hence PHP is necessary.”
“Patient lacks a safe recovery environment; without 24-hour care (residential) the risk of relapse and potential overdose is high (ASAM Dimension 6 issue).”
“Patient has failed two prior IOP programs (2019, 2020) – a more intensive approach (residential) is medically necessary now.”
Aetna’s reviewers appreciate when you tie it back to “why a lower level won’t work” because that is often their focus in denials. If you preempt that by explaining, you improve your chances. Also highlight evidence-based practices: e.g., “According to ASAM Criteria and the VA/DoD Clinical Practice Guideline which Aetna references (How to Use Humana's Clinical Guidelines for Behavioral Health in Your Addiction Treatment Center's Billing Department), this patient meets indications for opioid agonist therapy and concurrent counseling at IOP level.”
If Precert is denied: Aetna will send a letter citing the rationale, often quoting their Medical Necessity Criteria. For example, “Criteria not met for RTC: patient has no recent failure of outpatient treatment.” If you receive a denial that you disagree with, you can request a peer-to-peer review with an Aetna medical director or file an appeal. During a peer-to-peer, be prepared with any additional info. A common scenario: Aetna denies residential, saying patient could do IOP. You then present why IOP already failed or is not safe, possibly referencing guidelines or even parity (“Given the severity, treating at IOP would be akin to treating pneumonia with oral meds when hospitalization is indicated – not safe nor standard”).
Aetna is known for being a bit bureaucratic with precert, so persistence is key. Always note date/time of calls, reference numbers, and names of reps. If something isn’t clear, escalate to a supervisor or Aetna clinical liaison.
Important: Some Aetna plans outsource behavioral health to other companies (like Beacon Health Options or Magellan). If that’s the case, you’d actually precert through that vendor. Check the member’s ID card – if it says “Behavioral Health: call XYZ number,” use that. For instance, some Aetna Student Health plans use third-party administrators for mental health. Ensure you’re talking to the right entity for authorization.
Provider-friendly tip: Use Aetna’s own language when possible. Aetna’s glossary defines medically necessary services as those that are in line with generally accepted standards and not for convenience (How to Determine the Medical Necessity of Addiction Treatment Services for UnitedHealth Group, Inc). For example, say “This treatment is clinically appropriate and not for convenience; without it the patient is likely to deteriorate.” It sounds formal, but it addresses their criteria bullet points.
Additional resources: BehaveHealth has a blog post Everything You Ever Wanted to Know About Aetna Precertification for Addiction Treatment Billing which is extremely useful. It explains Aetna’s precert process, notes that terms like precertification and preauthorization mean the same for Aetna, and importantly highlights how some laws forced Aetna to stop requiring preauthorization for IOP and ambulatory detox from 2019 onward (Everything You Ever Wanted to Know About Aetna Precertification for Addiction Treatment Billing). Reviewing that post can give providers insight into navigating Aetna’s requirements and avoiding unnecessary precert efforts when not needed. It also cautions about the unreliable “search by CPT” function on Aetna’s site for precert (which shows false negatives for BH codes) (Everything You Ever Wanted to Know About Aetna Precertification for Addiction Treatment Billing) – a good reminder to always consult official precert lists or call Aetna directly.
Billing Codes and Nuances for Aetna (CVS Health)
When billing Aetna for SUD treatment services, it’s important to use the codes that match what was authorized and to follow any insurer-specific coding rules. Some nuances with Aetna include their use of specific modifiers on claims for certain programs and the way they handle claim edits.
Common SUD service codes and Aetna notes:
Assessment & Diagnosis: H0001 for initial assessment (covered without auth typically). Aetna might bundle this into the first day of treatment if done on admission to a program.
Outpatient therapy: 908XX CPT codes. No auth required usually. Aetna allows up to a certain number of visits (like 20) before even thinking of medical necessity review, but with parity, they don’t impose hard limits.
IOP/PHP: We covered H0015 (IOP) and S0201 (PHP). One nuance: Aetna may require billing on a UB-04 form for PHP/IOP if it’s a facility-based program. Make sure to include the correct revenue code (0905 for IOP, 0912 for PHP often). If you bill on a CMS-1500 instead, it might deny for invalid billing type. Check your contract – some providers (like physician groups) can’t bill IOP, it has to be the facility.
Urine Drug Testing: Aetna has specific policies on drug testing frequency. Usually, presumptive tests (CPT 80305-80307) are covered up to weekly in IOP/PHP, and definitive tests (HCPCS G0480-G0483) when medically necessary. Overuse can trigger denials. Also, Aetna’s claims might bundle lab tests in facility payments if done on-site. Be cautious not to unbundle improperly.
Medication management visits: If a patient is in an IOP or PHP, the psychiatric or MAT medication management might be considered part of that program’s rate (especially PHP). But if separate, use E/M codes with add-on code if required. Some Aetna plans use HP modifier for physician and HN for bachelor-level, etc., to indicate provider level in documentation.
Telehealth services: Post-2020, Aetna expanded coverage for tele-behavioral health. If you provide IOP or therapy via telehealth, append Modifier 95 or GT as instructed by Aetna’s telehealth policy. They reimbursed virtual IOP during COVID and likely still do with appropriate modifiers.
Aetna’s claims systems are usually sophisticated due to CVS integration. Expect them to enforce NCCI edits (so don’t, for example, bill individual therapy on the same day as IOP - they won’t pay both). Also, Aetna requires correct coding of place of service (POS). E.g., POS 53 for IOP (community mental health center) or POS 22 (outpatient hospital) for PHP depending on setting. Incorrect POS can lead to rejections or reduced payment.
Billing for ancillary services: If your program provides transportation or recovery support services, note that Aetna typically doesn’t reimburse those (unless part of a state Medicaid contract with SUD case management codes etc.). Focus on billing the core treatment codes.
Coding for concurrent behavioral conditions: If treating co-occurring mental health issues, you might bill some codes like 90833 (therapy add-on to med visit) or psychological testing codes. These need separate auth only if not part of the SUD treatment authorization. Usually therapy is therapy – doesn’t matter if SUD or MH focus. Aetna’s parity compliance means no separate limit on mental health vs SUD visits.
One more nuance: Aetna’s claim payment is tied to the authorization. They often require the authorization number on the claim (though electronically it usually matches by member ID and date). If there’s any mismatch (e.g., you billed H0015 on dates not included in the auth span), they will deny saying no auth. So ensure your billing department lines up the dates of service and codes exactly with what was authorized.
Lastly, keep an eye on billing code updates. For instance, CMS introduced new codes for Remote Patient Monitoring and some SUD-related services; Aetna may adopt these in time. Checking Aetna’s provider updates or the CVS Health policy portal annually is wise to catch changes (like if they start using ASAM 4th edition criteria or adopt any new billing requirements).
In summary, working with Aetna involves rigor in precertification and alignment with ASAM criteria for clinical justification. But once authorized, Aetna will pay for the services as long as you bill correctly. The insurer’s integration with CVS Health and emphasis on evidence-based guidelines (they even cite the VA/DOD SUD guidelines in their resources (How to Use Humana's Clinical Guidelines for Behavioral Health in Your Addiction Treatment Center's Billing Department)) means providers who follow best practices in addiction treatment will find Aetna receptive. Always double-check precert needs, keep documentation robust, and use the appropriate codes, and you can successfully secure coverage and reimbursement from Aetna for the full continuum of addiction care.