Aetna · Clinical coverage policy

Aetna Cardiac Catheter Ablation coverage criteria

Aetna CPB 0165 covers cardiac catheter ablation with electrophysiological studies as medically necessary for a defined list of arrhythmias - atrial fibrillation, AVNRT, atrial tachycardia/flutter, accessory-pathway tachycardias (including WPW), and ventricular arrhythmias - generally gated on the arrhythmia being symptomatic and/or drug-resistant, drug-intolerant, drug-contraindicated, or not desired by the member. Pulsed field ablation is accepted as an equivalent alternative to radiofrequency ablation. Several specific techniques (e.g., alcohol ablation of the vein of Marshall, AtriCure Isolator Synergy EnCompass Clamp, cardio-neuro-ablation for syncope/carotid sinus hypersensitivity, intra-myocardial infusion-needle ablation for VT, non-invasive cardiac radio-ablation, and sinus node-sparing hybrid ablation) and all other unlisted indications are considered experimental/investigational.

Policy CPB 0165 · Effective · Verify against the current Aetna policy before submitting — view source policy.

Payer

Aetna

Policy

CPB 0165

Prior auth

Confirm

Effective

April 20, 1999

This page reflects the coverage criteria captured from Aetna policy CPB 0165 and may not include every criterion, exception, or code — verify the complete bulletin before submitting.

What this means for the claim

The covered path, the next step to get it approved, and the specific way it denies — built only from this policy.

When does Aetna cover Cardiac Catheter Ablation (CPT 93613), and what gets it denied?

Path
Aetna CPB 0165 covers cardiac catheter ablation with electrophysiological studies as medically necessary for a defined list of arrhythmias - atrial fibrillation, AVNRT, atrial tachycardia/flutter, accessory-pathway tachycardias (including WPW), and ventricular arrhythmias - generally gated on the arrhythmia being symptomatic and/or drug-resistant, drug-intolerant, drug-contraindicated, or not desired by the member. Pulsed field ablation is accepted as an equivalent alternative to radiofrequency ablation. Several specific techniques (e.g., alcohol ablation of the vein of Marshall, AtriCure Isolator Synergy EnCompass Clamp, cardio-neuro-ablation for syncope/carotid sinus hypersensitivity, intra-myocardial infusion-needle ablation for VT, non-invasive cardiac radio-ablation, and sinus node-sparing hybrid ablation) and all other unlisted indications are considered experimental/investigational. Coverage criteria include: GENERAL: Aetna considers cardiac catheter ablation procedures with electrophysiological studies medically necessary for ANY of the listed arrhythmias below.; ATRIAL FIBRILLATION (AF) - medically necessary for members with AF who meet ANY of the following (items below): Symptomatic AF when anti-arrhythmic drugs have been ineffective, contraindicated, not tolerated, or not preferred; AF with inadequately controlled ventricular rates; AF with an identified accessory pathway; AF with heart failure with reduced ejection fraction or suspected tachycardia-mediated cardiomyopathy; Symptomatic AF and heart failure with preserved ejection fraction; Hypertrophic cardiomyopathy with AF that is drug-resistant, drugs are not tolerated or are contraindicated, or the member does not wish to take them; Symptomatic AF amenable to catheter ablation where symptoms persist despite rate control; Symptomatic paroxysmal AF when rhythm control is desired; Recurrent implantable cardioverter-defibrillator (ICD) shocks delivered for atrial fibrillation with rapid ventricular response, when shocks are not manageable by reprogramming or adjustment of medications; Atrioventricular nodal ablation for members with AF, heart failure with reduced ejection fraction, and poor rate control; Atrioventricular nodal ablation for members with AF, heart failure with reduced ejection fraction, and biventricular pacing in whom an adequate pacing percentage cannot be achieved; Atrioventricular nodal ablation for members with AF and uncontrolled rapid ventricular response refractory to rate-control medications (who are not candidates for, or in whom rhythm control has been unsuccessful); Asymptomatic paroxysmal AF in a young member with few co-morbidities; ATRIOVENTRICULAR NODAL REENTRANT TACHYCARDIA (AVNRT) - medically necessary in members with atrioventricular node reentrant tachycardia; ATRIAL TACHYCARDIA (AT) / ATRIAL FLUTTER (AFL) - medically necessary in members who meet ANY of the following (items below): Members with atrial flutter (AFL); Members with focal or multifocal atrial tachycardia (AT); Junctional tachycardia that is drug-resistant, drugs are not tolerated or are contraindicated, or the member does not wish to take them; AT/AFL with tachycardia-mediated cardiomyopathy; AT/AFL with tachy-brady syndrome / sinus node dysfunction; ACCESSORY PATHWAYS - medically necessary in members with accessory pathway tachycardia (including pre-excitation syndrome, e.g., Wolff-Parkinson-White syndrome); ACCESSORY PATHWAYS - medically necessary in members with Wolff-Parkinson-White syndrome WITHOUT tachycardia who have a high-risk accessory pathway based on treadmill testing OR electrophysiologic testing; VENTRICULAR ARRHYTHMIA - medically necessary in members who meet ANY of the following (items below): Arrhythmogenic right ventricular cardiomyopathy (ARVC) with recurrent sustained VT or frequent appropriate ICD shocks in whom a beta-blocker is ineffective or not tolerated (catheter ablation with availability of a combined endocardial/epicardial approach can be beneficial); Frequent (e.g., greater than 15% of beats) premature ventricular contractions (PVCs) who have declining ventricular function due to PVCs, when the PVCs are drug-resistant, or drugs are contraindicated or not tolerated, or the member does not desire long-term drug therapy; Non-responders to cardiac resynchronization therapy with frequent unifocal premature ventricular contractions limiting optimal biventricular pacing despite drug therapy; Non-sustained VT that is symptomatic when the tachycardia is drug-resistant, drugs are contraindicated, or the member is drug-intolerant or does not desire long-term drug therapy; Recurrent episodes of idiopathic VF or polymorphic VT initiated by PVCs with consistent QRS morphology; Suspected epicardial substrate or circuit on ECG when the tachycardia is drug-resistant, or drugs are contraindicated or not tolerated, or the member does not desire long-term drug therapy; Symptomatic ventricular arrhythmias in a structurally normal heart (e.g., idiopathic, papillary muscle, outflow tract) where the arrhythmia is drug-resistant, or drugs are contraindicated or not tolerated, or the member does not desire long-term drug therapy; VT related to re-entry (e.g., bundle branch, His-Purkinje, or fascicular) when the tachycardia is drug-resistant, or drugs are contraindicated or not tolerated, or the member does not desire long-term drug therapy; Recurrent sustained monomorphic VT or recurrent appropriate ICD shocks not manageable by re-programming or concomitant drug therapy; Ischemic heart disease with recurrent monomorphic VT when anti-arrhythmic drug therapy has failed, is contraindicated, is not tolerated, or is not desired; OPERATIVE ABLATION - see CPB 0225 (Maze Procedure); PULSED FIELD ABLATION: For purposes of this policy, pulsed field ablation is considered an equally acceptable alternative to standard radiofrequency ablation for the medically necessary indications.; ELECTROPHYSIOLOGY STUDY TIMING: For members who undergo an electrophysiology study on the same day as an ablation, an electrophysiologic study is considered medically necessary if no prior electrophysiology study has been performed within the previous 3 months.; CARTO SYSTEM: Use of the CARTO system (an intra-cardiac electrophysiological 3-D mapping system) is considered medically necessary for guiding radiofrequency ablation in the treatment of arrhythmias.; PHYSICIAN REQUIREMENT (procedural note): Two electrophysiologists are required to perform the ablation - one to manipulate the catheters, and the other to guide the precise location for the ablation utilizing electrogram analysis and pacing.; PACEMAKER PLACEMENT (procedural note): The procedure includes temporary pacemaker placement if indicated; when ablation of the His-bundle is indicated, a permanent pacemaker will always be placed because the ablation has caused a complete heart block.. Applies to 14 codes: 93613, 93650, 93653, 93654, 93655, 93656, 93657, 33250, 33251, 33254, 33256, 33257, 33259, 33261.
Action
Confirm prior-authorization status with Aetna before scheduling — it is code- and plan-specific, and this policy is not an exact authorization source.
Trap
Policy exclusions and limitations: Aetna considers cardiac catheter ablation procedures experimental, investigational, or unproven for all OTHER indications (i.e., any indication not listed as medically necessary), as there is insufficient evidence in the peer-reviewed medical literature of effectiveness for these indications.; Experimental, investigational, or unproven: Alcohol ablation of vein of Marshall for the treatment of paroxysmal/persistent atrial fibrillation, peri-mitral flutter, or premature ventricular contraction.; Experimental, investigational, or unproven: Cardiac catheter ablation using the AtriCure Isolator Synergy EnCompass Clamp.; Experimental, investigational, or unproven: Cardio-neuro-ablation (including ablation of intracardiac ganglia) for the treatment of carotid sinus hypersensitivity.; Experimental, investigational, or unproven: Cardio-neuro-ablation (including ablation of intracardiac ganglia) for the treatment of syncope.; Experimental, investigational, or unproven: Intra-myocardial infusion-needle catheter ablation for ventricular tachycardia.; Experimental, investigational, or unproven: Non-invasive cardiac radio-ablation for the treatment of cardiac arrhythmias (e.g., atrial fibrillation (AF) and VT).; Experimental, investigational, or unproven: Sinus node-sparing hybrid ablation for the treatment of sinus tachycardia / postural orthostatic sinus tachycardia. Claims may be denied when the requested service falls under these.

Source: Aetna CPB 0165 — Cardiac Catheter Ablation

Coverage criteria

  • GENERAL: Aetna considers cardiac catheter ablation procedures with electrophysiological studies medically necessary for ANY of the listed arrhythmias below.
  • ATRIAL FIBRILLATION (AF) - medically necessary for members with AF who meet ANY of the following (items below): Symptomatic AF when anti-arrhythmic drugs have been ineffective, contraindicated, not tolerated, or not preferred
  • AF with inadequately controlled ventricular rates
  • AF with an identified accessory pathway
  • AF with heart failure with reduced ejection fraction or suspected tachycardia-mediated cardiomyopathy
  • Symptomatic AF and heart failure with preserved ejection fraction
  • Hypertrophic cardiomyopathy with AF that is drug-resistant, drugs are not tolerated or are contraindicated, or the member does not wish to take them
  • Symptomatic AF amenable to catheter ablation where symptoms persist despite rate control
  • Symptomatic paroxysmal AF when rhythm control is desired
  • Recurrent implantable cardioverter-defibrillator (ICD) shocks delivered for atrial fibrillation with rapid ventricular response, when shocks are not manageable by reprogramming or adjustment of medications
  • Atrioventricular nodal ablation for members with AF, heart failure with reduced ejection fraction, and poor rate control
  • Atrioventricular nodal ablation for members with AF, heart failure with reduced ejection fraction, and biventricular pacing in whom an adequate pacing percentage cannot be achieved
  • Atrioventricular nodal ablation for members with AF and uncontrolled rapid ventricular response refractory to rate-control medications (who are not candidates for, or in whom rhythm control has been unsuccessful)
  • Asymptomatic paroxysmal AF in a young member with few co-morbidities
  • ATRIOVENTRICULAR NODAL REENTRANT TACHYCARDIA (AVNRT) - medically necessary in members with atrioventricular node reentrant tachycardia
  • ATRIAL TACHYCARDIA (AT) / ATRIAL FLUTTER (AFL) - medically necessary in members who meet ANY of the following (items below): Members with atrial flutter (AFL)
  • Members with focal or multifocal atrial tachycardia (AT)
  • Junctional tachycardia that is drug-resistant, drugs are not tolerated or are contraindicated, or the member does not wish to take them
  • AT/AFL with tachycardia-mediated cardiomyopathy
  • AT/AFL with tachy-brady syndrome / sinus node dysfunction
  • ACCESSORY PATHWAYS - medically necessary in members with accessory pathway tachycardia (including pre-excitation syndrome, e.g., Wolff-Parkinson-White syndrome)
  • ACCESSORY PATHWAYS - medically necessary in members with Wolff-Parkinson-White syndrome WITHOUT tachycardia who have a high-risk accessory pathway based on treadmill testing OR electrophysiologic testing
  • VENTRICULAR ARRHYTHMIA - medically necessary in members who meet ANY of the following (items below): Arrhythmogenic right ventricular cardiomyopathy (ARVC) with recurrent sustained VT or frequent appropriate ICD shocks in whom a beta-blocker is ineffective or not tolerated (catheter ablation with availability of a combined endocardial/epicardial approach can be beneficial)
  • Frequent (e.g., greater than 15% of beats) premature ventricular contractions (PVCs) who have declining ventricular function due to PVCs, when the PVCs are drug-resistant, or drugs are contraindicated or not tolerated, or the member does not desire long-term drug therapy
  • Non-responders to cardiac resynchronization therapy with frequent unifocal premature ventricular contractions limiting optimal biventricular pacing despite drug therapy
  • Non-sustained VT that is symptomatic when the tachycardia is drug-resistant, drugs are contraindicated, or the member is drug-intolerant or does not desire long-term drug therapy
  • Recurrent episodes of idiopathic VF or polymorphic VT initiated by PVCs with consistent QRS morphology
  • Suspected epicardial substrate or circuit on ECG when the tachycardia is drug-resistant, or drugs are contraindicated or not tolerated, or the member does not desire long-term drug therapy
  • Symptomatic ventricular arrhythmias in a structurally normal heart (e.g., idiopathic, papillary muscle, outflow tract) where the arrhythmia is drug-resistant, or drugs are contraindicated or not tolerated, or the member does not desire long-term drug therapy
  • VT related to re-entry (e.g., bundle branch, His-Purkinje, or fascicular) when the tachycardia is drug-resistant, or drugs are contraindicated or not tolerated, or the member does not desire long-term drug therapy
  • Recurrent sustained monomorphic VT or recurrent appropriate ICD shocks not manageable by re-programming or concomitant drug therapy
  • Ischemic heart disease with recurrent monomorphic VT when anti-arrhythmic drug therapy has failed, is contraindicated, is not tolerated, or is not desired
  • OPERATIVE ABLATION - see CPB 0225 (Maze Procedure)
  • PULSED FIELD ABLATION: For purposes of this policy, pulsed field ablation is considered an equally acceptable alternative to standard radiofrequency ablation for the medically necessary indications.
  • ELECTROPHYSIOLOGY STUDY TIMING: For members who undergo an electrophysiology study on the same day as an ablation, an electrophysiologic study is considered medically necessary if no prior electrophysiology study has been performed within the previous 3 months.
  • CARTO SYSTEM: Use of the CARTO system (an intra-cardiac electrophysiological 3-D mapping system) is considered medically necessary for guiding radiofrequency ablation in the treatment of arrhythmias.
  • PHYSICIAN REQUIREMENT (procedural note): Two electrophysiologists are required to perform the ablation - one to manipulate the catheters, and the other to guide the precise location for the ablation utilizing electrogram analysis and pacing.
  • PACEMAKER PLACEMENT (procedural note): The procedure includes temporary pacemaker placement if indicated; when ablation of the His-bundle is indicated, a permanent pacemaker will always be placed because the ablation has caused a complete heart block.

Covered codes

Codes listed in this Aetna policy. Check each one's prior-authorization verdict and Medicare rate:

Frequently asked questions

When does Aetna cover Cardiac Catheter Ablation (CPT 93613), and what gets it denied?
Aetna CPB 0165 covers cardiac catheter ablation with electrophysiological studies as medically necessary for a defined list of arrhythmias - atrial fibrillation, AVNRT, atrial tachycardia/flutter, accessory-pathway tachycardias (including WPW), and ventricular arrhythmias - generally gated on the arrhythmia being symptomatic and/or drug-resistant, drug-intolerant, drug-contraindicated, or not desired by the member. Pulsed field ablation is accepted as an equivalent alternative to radiofrequency ablation. Several specific techniques (e.g., alcohol ablation of the vein of Marshall, AtriCure Isolator Synergy EnCompass Clamp, cardio-neuro-ablation for syncope/carotid sinus hypersensitivity, intra-myocardial infusion-needle ablation for VT, non-invasive cardiac radio-ablation, and sinus node-sparing hybrid ablation) and all other unlisted indications are considered experimental/investigational. Coverage criteria include: GENERAL: Aetna considers cardiac catheter ablation procedures with electrophysiological studies medically necessary for ANY of the listed arrhythmias below.; ATRIAL FIBRILLATION (AF) - medically necessary for members with AF who meet ANY of the following (items below): Symptomatic AF when anti-arrhythmic drugs have been ineffective, contraindicated, not tolerated, or not preferred; AF with inadequately controlled ventricular rates; AF with an identified accessory pathway; AF with heart failure with reduced ejection fraction or suspected tachycardia-mediated cardiomyopathy; Symptomatic AF and heart failure with preserved ejection fraction; Hypertrophic cardiomyopathy with AF that is drug-resistant, drugs are not tolerated or are contraindicated, or the member does not wish to take them; Symptomatic AF amenable to catheter ablation where symptoms persist despite rate control; Symptomatic paroxysmal AF when rhythm control is desired; Recurrent implantable cardioverter-defibrillator (ICD) shocks delivered for atrial fibrillation with rapid ventricular response, when shocks are not manageable by reprogramming or adjustment of medications; Atrioventricular nodal ablation for members with AF, heart failure with reduced ejection fraction, and poor rate control; Atrioventricular nodal ablation for members with AF, heart failure with reduced ejection fraction, and biventricular pacing in whom an adequate pacing percentage cannot be achieved; Atrioventricular nodal ablation for members with AF and uncontrolled rapid ventricular response refractory to rate-control medications (who are not candidates for, or in whom rhythm control has been unsuccessful); Asymptomatic paroxysmal AF in a young member with few co-morbidities; ATRIOVENTRICULAR NODAL REENTRANT TACHYCARDIA (AVNRT) - medically necessary in members with atrioventricular node reentrant tachycardia; ATRIAL TACHYCARDIA (AT) / ATRIAL FLUTTER (AFL) - medically necessary in members who meet ANY of the following (items below): Members with atrial flutter (AFL); Members with focal or multifocal atrial tachycardia (AT); Junctional tachycardia that is drug-resistant, drugs are not tolerated or are contraindicated, or the member does not wish to take them; AT/AFL with tachycardia-mediated cardiomyopathy; AT/AFL with tachy-brady syndrome / sinus node dysfunction; ACCESSORY PATHWAYS - medically necessary in members with accessory pathway tachycardia (including pre-excitation syndrome, e.g., Wolff-Parkinson-White syndrome); ACCESSORY PATHWAYS - medically necessary in members with Wolff-Parkinson-White syndrome WITHOUT tachycardia who have a high-risk accessory pathway based on treadmill testing OR electrophysiologic testing; VENTRICULAR ARRHYTHMIA - medically necessary in members who meet ANY of the following (items below): Arrhythmogenic right ventricular cardiomyopathy (ARVC) with recurrent sustained VT or frequent appropriate ICD shocks in whom a beta-blocker is ineffective or not tolerated (catheter ablation with availability of a combined endocardial/epicardial approach can be beneficial); Frequent (e.g., greater than 15% of beats) premature ventricular contractions (PVCs) who have declining ventricular function due to PVCs, when the PVCs are drug-resistant, or drugs are contraindicated or not tolerated, or the member does not desire long-term drug therapy; Non-responders to cardiac resynchronization therapy with frequent unifocal premature ventricular contractions limiting optimal biventricular pacing despite drug therapy; Non-sustained VT that is symptomatic when the tachycardia is drug-resistant, drugs are contraindicated, or the member is drug-intolerant or does not desire long-term drug therapy; Recurrent episodes of idiopathic VF or polymorphic VT initiated by PVCs with consistent QRS morphology; Suspected epicardial substrate or circuit on ECG when the tachycardia is drug-resistant, or drugs are contraindicated or not tolerated, or the member does not desire long-term drug therapy; Symptomatic ventricular arrhythmias in a structurally normal heart (e.g., idiopathic, papillary muscle, outflow tract) where the arrhythmia is drug-resistant, or drugs are contraindicated or not tolerated, or the member does not desire long-term drug therapy; VT related to re-entry (e.g., bundle branch, His-Purkinje, or fascicular) when the tachycardia is drug-resistant, or drugs are contraindicated or not tolerated, or the member does not desire long-term drug therapy; Recurrent sustained monomorphic VT or recurrent appropriate ICD shocks not manageable by re-programming or concomitant drug therapy; Ischemic heart disease with recurrent monomorphic VT when anti-arrhythmic drug therapy has failed, is contraindicated, is not tolerated, or is not desired; OPERATIVE ABLATION - see CPB 0225 (Maze Procedure); PULSED FIELD ABLATION: For purposes of this policy, pulsed field ablation is considered an equally acceptable alternative to standard radiofrequency ablation for the medically necessary indications.; ELECTROPHYSIOLOGY STUDY TIMING: For members who undergo an electrophysiology study on the same day as an ablation, an electrophysiologic study is considered medically necessary if no prior electrophysiology study has been performed within the previous 3 months.; CARTO SYSTEM: Use of the CARTO system (an intra-cardiac electrophysiological 3-D mapping system) is considered medically necessary for guiding radiofrequency ablation in the treatment of arrhythmias.; PHYSICIAN REQUIREMENT (procedural note): Two electrophysiologists are required to perform the ablation - one to manipulate the catheters, and the other to guide the precise location for the ablation utilizing electrogram analysis and pacing.; PACEMAKER PLACEMENT (procedural note): The procedure includes temporary pacemaker placement if indicated; when ablation of the His-bundle is indicated, a permanent pacemaker will always be placed because the ablation has caused a complete heart block.. Applies to 14 codes: 93613, 93650, 93653, 93654, 93655, 93656, 93657, 33250, 33251, 33254, 33256, 33257, 33259, 33261. Confirm prior-authorization status with Aetna before scheduling — it is code- and plan-specific, and this policy is not an exact authorization source. Policy exclusions and limitations: Aetna considers cardiac catheter ablation procedures experimental, investigational, or unproven for all OTHER indications (i.e., any indication not listed as medically necessary), as there is insufficient evidence in the peer-reviewed medical literature of effectiveness for these indications.; Experimental, investigational, or unproven: Alcohol ablation of vein of Marshall for the treatment of paroxysmal/persistent atrial fibrillation, peri-mitral flutter, or premature ventricular contraction.; Experimental, investigational, or unproven: Cardiac catheter ablation using the AtriCure Isolator Synergy EnCompass Clamp.; Experimental, investigational, or unproven: Cardio-neuro-ablation (including ablation of intracardiac ganglia) for the treatment of carotid sinus hypersensitivity.; Experimental, investigational, or unproven: Cardio-neuro-ablation (including ablation of intracardiac ganglia) for the treatment of syncope.; Experimental, investigational, or unproven: Intra-myocardial infusion-needle catheter ablation for ventricular tachycardia.; Experimental, investigational, or unproven: Non-invasive cardiac radio-ablation for the treatment of cardiac arrhythmias (e.g., atrial fibrillation (AF) and VT).; Experimental, investigational, or unproven: Sinus node-sparing hybrid ablation for the treatment of sinus tachycardia / postural orthostatic sinus tachycardia. Claims may be denied when the requested service falls under these.
Does Aetna require prior authorization for Cardiac Catheter Ablation?
Confirm prior-authorization status with Aetna before scheduling — it is code- and plan-specific, and this policy is not an exact authorization source.
What does Aetna exclude for Cardiac Catheter Ablation?
Policy exclusions and limitations: Aetna considers cardiac catheter ablation procedures experimental, investigational, or unproven for all OTHER indications (i.e., any indication not listed as medically necessary), as there is insufficient evidence in the peer-reviewed medical literature of effectiveness for these indications.; Experimental, investigational, or unproven: Alcohol ablation of vein of Marshall for the treatment of paroxysmal/persistent atrial fibrillation, peri-mitral flutter, or premature ventricular contraction.; Experimental, investigational, or unproven: Cardiac catheter ablation using the AtriCure Isolator Synergy EnCompass Clamp.; Experimental, investigational, or unproven: Cardio-neuro-ablation (including ablation of intracardiac ganglia) for the treatment of carotid sinus hypersensitivity.; Experimental, investigational, or unproven: Cardio-neuro-ablation (including ablation of intracardiac ganglia) for the treatment of syncope.; Experimental, investigational, or unproven: Intra-myocardial infusion-needle catheter ablation for ventricular tachycardia.; Experimental, investigational, or unproven: Non-invasive cardiac radio-ablation for the treatment of cardiac arrhythmias (e.g., atrial fibrillation (AF) and VT).; Experimental, investigational, or unproven: Sinus node-sparing hybrid ablation for the treatment of sinus tachycardia / postural orthostatic sinus tachycardia. Claims may be denied when the requested service falls under these.

Source

Aetna CPB 0165 — Cardiac Catheter Ablation

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Coverage disclaimer

This page summarizes Aetna clinical-coverage criteria extracted from policy CPB 0165 for educational purposes. Coverage policies change and vary by individual plan. Always verify against Aetna's current policy before performing a procedure or submitting a claim. d3rx is not responsible for claim denials or reimbursement issues.