Aetna

Appeal Deadlines

Commercial: 180 days from denial date

Medicare: 60 days for Medicare Advantage

Key Facts

• +Aetna publishes Clinical Policy Bulletins (CPBs) that define their medical necessity criteria for specific services. Appeals referencing the specific CPB succeed at significantly higher rates than generic appeals.
• +Aetna's 180-day commercial appeal deadline gives you more time than UHC but the deadline is still firm.
• +Aetna's ACA marketplace denial rate of 22% is consistent with the industry average of 19%.
• +Aetna was rated by 57% of physicians as having high or extremely high prior authorization burden.

What to Watch

• +If your denial cites medical necessity, find the specific CPB that applies to your service before appealing. CPBs are publicly available on Aetna's website.
• +Aetna's prior authorization requirements vary significantly by plan type. Verify requirements before scheduling procedures.

Appeal Tips

1. Search Aetna's CPB library for the policy covering your denied service. Address every criterion in the CPB directly in your appeal.
2. Include your physician's clinical notes, relevant lab or imaging results, and a letter from your doctor specifically addressing Aetna's medical necessity criteria.
3. If your internal appeal is denied, request an external review. External reviewers are independent of Aetna and overturn internal decisions in a significant percentage of cases.

Resources

• Aetna Clinical Policy Bulletins
• Aetna Member Appeals