Aetna Commercial Clinical Policy

Aetna Outpatient Medical Self-Care Programs Form

Effective Date

08/14/1997

Last Reviewed

03/31/2023

Original Document

  Reference



Background for this Policy

Outpatient medical self-care programs refer to programs that focus on self-care activities for management of disease. Self-care programs follow evidence based guidelines, and may refer to diet, exercise, administration of medications, monitoring disease, avoiding activities that exacerbate disease, and obtaining recommended follow-up medical care. Another important part of self-care is being able to recognize the need for medical care.

Scope of Policy

This Clinical Policy Bulletin addresses outpatient medical self-care programs.

Medical Necessity

Aetna considers the following interventions medically necessary:

Outpatient medical self-care programs (subject to applicable plan coverage definitions and limitations; please check benefit plan descriptions for details):

  • Back school for members with chronic back pain who meet criteria in
    • CPB 0232 - Back Pain - Non Invasive Treatments
  • ;
  • Cardiac rehabilitation for members with cardiac disease who meet criteria in
    • CPB 0021 - Cardiac Rehabilitation
  • ;
  • Diabetes education programs for members with diabetes who meet criteria in
    • CPB 0070 - Diabetes Tests, Programs and Supplies
  • ;
  • Pulmonary rehabilitation for members with chronic pulmonary diseases who meet criteria in
    • CPB 0032 - Pulmonary Rehabilitation
  • .

    • Recognized programs

    Consideration of coverage will be extended to other self-care programs (subject to plan coverage definitions and limitations; please check benefit plan descriptions) when:

  • The program consists of services provided by recognized health care professionals (e.g., doctors, registered nurses, social workers, physical therapists, dietitians
    • Footnote *
  • , respiratory therapist
    • Footnote *
  • , etc.);
    • and
  • The program is coordinated with Aetna's Patient Management Department (in Aetna network plans);
    • and
  • The program is designed to educate the member about specific conditions and lifestyle changes necessary as a result of the medical condition;
    • and
  • The program is directed and supervised by a physician;
    • and

    The program is prescribed by the attending physician for a member with a medical condition amenable to self-care (e.g., diabetes, chronic back pain, chronic pulmonary disease or cardiac disease).

    Note

    Frequency and Duration

    : The medically necessary frequency and duration of self-care programs varies depending on the goals and objectives of the program. Participation in a self-care program for a particular illness is considered medically necessary once per lifetime unless an additional episode of illness requires another self-care program (e.g., second heart attack).

    Footnote1 *Services Provided by Dietitians and Respiratory Therapists:

    Self-care programs offering services provided by dietitians and respiratory therapists may be covered when required by law or when

    all

    of the following criteria are met:

  • The charges are billed by their doctor or hospital employer; and
  • The services are covered under the policy; and
  • They are employed by and working under the supervision of a hospital or recognized health care facility, a home health care agency or a qualified doctor; and
  • They are licensed, certified or qualified by professional credentials or degree to provide the services.

    • Policy Limitations and Exclusions

    Non-covered programs

    Coverage is not extended for self-care programs that:

  • Are available to the general public without charge; or
  • Are general health or lifestyle education programs – not related to the member's diagnosis or condition; or
  • Consist of services not generally accepted as necessary and appropriate for management of the disease or injury.

    • Work Hardening Programs

    Work hardening programs are not considered covered outpatient self-care programs under Aetna medical plans.

    Note:

    The primary goal of these programs is return to work, not treatment of a disease or injury. Their purpose is training the individual to work with their current limitations and to be able to function with maximum productivity in their job. This is a form of vocational rehabilitation rather than a covered outpatient self-care program.