CIGNA/ASH MEDICAL COVERAGE POLICIES

INSTRUCTIONS FOR USE

Cigna / American Specialty Health (ASH) Medical Coverage Policies are used to assist in making utilization review and benefit determinations for health benefit plans administered by Cigna Companies. Certain Cigna Companies and/or lines of business only provide utilization review services to clients and do not make benefit determinations. References to standard benefit plan language and benefit determinations do not apply to those clients.

Cigna / ASH Medical Coverage Policies are intended to provide guidance in interpreting certain standard benefit plans administered by Cigna Companies. Please note, the terms of a customer's particular benefit plan document may differ significantly from the standard benefit plans upon which these Cigna / ASH Medical Coverage Policies are based. For example, a customer's benefit plan document may contain a specific exclusion related to a topic addressed in a Cigna / ASH Medical Coverage Policy. In the event of a conflict, a customer's benefit plan document always supersedes the information in the Cigna / ASH Medical Coverage Policy. In the absence of a controlling federal or state coverage mandate, benefits are ultimately determined by the terms of the applicable benefit plan document. Determinations in each specific instance may require consideration of:

1) The terms of the applicable benefit plan document in effect on the date of service
2) Any applicable laws/regulations
3) Any relevant collateral source materials including Cigna-ASH Medical Coverage Policies and
4) The specific facts of the particular situation

Cigna / ASH Medical Coverage Policies relate exclusively to the administration of health benefit plans.

Cigna / ASH Medical Coverage Policies are not recommendations for treatment and should never be used as treatment guidelines.

Some information in these Coverage Policies may not apply to all benefit plans administered by Cigna.