89/AI/2AI8

3,4:22

61,721,884A2

AETNASTUDENT HEALTH

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XAetna
DearRequestor:

OneCharles Park Cambridge, 021 MA 4Z-1 254 Tel:(617) 218-8400 Fax;(860)907-4.656 vvww. aetnastu nthealth. de com

You haveroquested services medical for trealment needs be reyiewed that to to detormine medical necessity, In orderto review yourcondition medical for necessity a timelyand complete in menner. please provide thefollowing all information: o Corrpletedenclosed questionnaira. a All roquiredinformationas epecifiedin th enclosedguestionnaire. F/eesecomptefethe g"u_eslionneir"-, sabmit a letterof medisalnece.seifyend retum it fo fhe addrass llsfed below, attenfion Managedcare Deparft|ent. p{easebe advisedtfiaf e lettet of medicalnecesslty witiout suppartlng medical documentefion rb nol safiffcienf. OurMedical Review Teammakes detenrinetion a provided, based the informatipn on uponcompletion the review, written of a decision be sentto the treating will provider and patient.,This decision basedon patient is eligibitity benefit end information aveitabte at thetimeof the review.Planprovisions govemandpayment be based patient will wiil on eligibility available and benefits thetimeservices rehdered. at are Please notethefollowing: pre-determinations o A,llcomplete MUSTbe received least20 business at days priorto the proposed dateof service, o All information should sentto: be Aetna$tudentHealth Attn:Managed Care OneCharles Park Cambridge, 02142-1254 MA Or via Fex860-9074656 Sincerely,

AetnaStud_ent Health, farmerly knownas The Chiehertng Group Managed CareDepartment

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L4:22

6172188482

AETNA STUDENTHEALTH

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Attrchnrent A AETNASTUDEIIT NEALTH I{ FOR PRE-DETERMINATIOH MEPICAL ECES$ITY QUESTIONNAIRE Frese note: Thislorm shauld be complefed hy yourTreating Physialanwith lQD9& CPT4 codes to enaDroan apprcpriste determlnation' If coding ls not provlde4 t tis form wlll be retumed as incompleb.

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LastName;-First LocalAddreesr lD#SocialSecurity/Student School Name:DOB_

Name: ,. Phone:(*)--_ Daytime

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FHUlffi $sr5F6BtB-,sl'p'tHFffi tfrHIE'tfrt pteaseHilidenspece providedaron

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pieceafpapar,awrittendesctlptlanof t{,ndiilanFaswell a,sFpfiafe iniury,pleasepravidecomplete /ffreatrnenl/srclatadtoanacclden|al IQD-}cadir1g. d$ppropnte occuffad. including how,whenand wnarcfne ccident accr?enf details,

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of in F/easopnovlde, speca pmvidador on a sepralopiece of peper, a writlen deacripliort ffie Prpposed for M$dicat racammandatian spefla/ of Equipment, frafflefll,includiogorderlng Durabla (mustinclude specific withtheplmary suryary. assdciefed any Procedures/surgery, fallaw-uppracedurcs

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CFTcsde,sJ; N tr N CPT4 CFT4 CPT4

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CPT4 CPT4 CPT4

D6teof Froposedsurgery/treatment:

Deteof first

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(QVER23 HOURS) INPAflENT (UNDER tr AMBULATORY/OBSERVATION 23 HOURS) tr OFFICE tr

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tr REOUEST INJECTIBLE

89/AIl2AIA 14:22

5172188402

AETNA STUDENTHEALTH

PAGE 84/A4

Attachment B AETNA$TUtrENTHEALTH PRE.DETERMIHATION MET}ICAL ECESSITY FON. N QUESTIONNAIRE PresBnote: This farm should be comptetedhy yaur Trcating physialanwlth tEDe& CpT4

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ITIHU"IdAHFHCIRD$
Qopies medical of records: Legible copiesof afl madicalrecords -* pathorogy LaboratoryActuafimaging.$tudies fitm$) (cr cephal6meidffrpsyrrraciifr gaw surgery) _ Diagnostie studymodels(iawsurgEry) Rdiology reports (nasat/sinuE surgery) Preoperative photos(allplastic.surgery, including breastsurgerylrhlnoplasty) Otherinformation; pleasespecify:

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NamEof treatingphysician: Address:

Number: Phone

Gity:

Speclalty: HeelthCenteior otnErconEcn

FaxNumher:

Stats:_

Zip:

Contact number: fax

Hospital/Facility:_

ffluress;',=--r' FhonE Number:

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H APPROVED requested as

tr APPROVED forthefollowing onty CpT4 codes:

H Additlonal information needed: is

il Denied the following for feasons:

A wdtten pre'determination benefls wifl be sent fo. of lhp .lyating physicianandhe patientupon comp/el/on of ffie revislu+ This d$t*rminal'rbn basedon the etiglbtltty beiems auitabtept the timeaf the review. is and Plan.provisions gorrcmand paymant ie bassd on atigibitity will wrfl and available benefltsat ilne, the sry,b?sarF rPndarod- lf yau disagreewith lhe detarmtnaltan, plpasefaffawthe appealsproccssas odlrned in the brcchure.