How to Appeal Denials from Aetna

We've all been there – you submit a claim to Aetna thinking it's rock solid, only to get that dreaded denial letter in return. Your first instinct might be to grumble about it over coffee and move on, but here's the thing: many of those denials are actually overturnable if you know how to work the system. Having dealt with hundreds of Aetna appeals over the years, I can tell you that this payer has its quirks, but they're also surprisingly responsive when you present your case correctly.

The key isn't just knowing how to appeal – it's understanding how Aetna thinks and what they're really looking for when they review your submission.

Understanding Aetna's Denial Patterns

Before you start crafting appeals, it helps to recognize that Aetna, now part of CVS Health, has become increasingly systematic in their approach to claim reviews. They're not just randomly denying claims – there's usually a specific trigger.

The most common denial reasons I see with Aetna include:

• Medical necessity questions (especially for diagnostic tests)


• Prior authorization oversights


• Coding issues, particularly with newer CPT codes


• Documentation that doesn't clearly support the level of service billed

Here's what I've learned: Aetna's reviewers often focus heavily on whether your documentation tells a complete clinical story. If they have to guess why you performed a service or prescribed a treatment, you're probably getting denied. For instance, if you bill for an echocardiogram but your notes only mention "chest pain" without any cardiac risk factors or abnormal findings, expect pushback.

One pattern I've noticed is that Aetna seems to have tightened up on diagnostic imaging approvals over the past couple of years. They're really scrutinizing whether conservative treatment was attempted first, especially for musculoskeletal conditions.

The Art of Timing Your Appeals

This might surprise you, but when you submit your appeal can be almost as important as what you submit. Aetna has specific timeframes – usually 180 days from the denial date for initial appeals – but don't wait until the last minute.

I've found that appeals submitted within 30-60 days of the denial tend to get more thorough reviews. My theory? The original claim is still relatively fresh in their system, and reviewers can more easily cross-reference your appeal with the initial submission.

Here's a practical tip: if you're dealing with a prior authorization denial, sometimes the fastest route isn't a formal appeal but rather a peer-to-peer review request. Aetna's medical directors are often more reasonable in real-time conversations than their initial review algorithms suggest.

For urgent situations – think surgical procedures or time-sensitive treatments – don't hesitate to request an expedited review. Aetna is actually pretty good about these when you can demonstrate genuine urgency, not just "my patient is impatient."

Building Your Case: Documentation That Actually Works

Let me be blunt: most appeal letters I see are weak sauce. They're either too generic ("please reconsider this denial") or they bury the important information in paragraphs of medical jargon that even other doctors would struggle to follow.

Aetna's reviewers want to see a clear narrative that connects the dots. Start with a brief summary of why the service was medically necessary, then provide supporting evidence in a logical order. I like to structure appeals like this:

Opening paragraph: State exactly what you're appealing and provide a one-sentence summary of why the denial was incorrect.

Clinical summary: Give them the patient's relevant history, current symptoms, and any previous treatments that were tried and failed.

Service justification: Explain specifically why this particular service/treatment was the appropriate next step.

Supporting evidence: Include relevant guidelines, studies, or policy references that support your position.

Here's a real example that worked: We had a denial for a cardiac stress test on a 45-year-old with atypical chest pain. The initial denial cited "no cardiac risk factors." Our appeal highlighted that the patient had a strong family history of early CAD (which was in our notes but apparently missed), had failed conservative treatment with antacids, and that current cardiology guidelines recommend stress testing for his demographic with these symptoms. We included specific references to ACC/AHA guidelines and got the reversal within two weeks.

Don't forget to include any additional documentation that wasn't available with the original claim. Sometimes patients mention crucial history in follow-up visits that completely changes the medical necessity picture.

Working the System: Escalation Strategies

If your first-level appeal gets denied, don't throw in the towel. Aetna has multiple levels of review, and I've seen cases flip completely at the second level, especially when you can get a peer-to-peer review with one of their medical directors.

The secret sauce for second-level appeals? Address the specific concerns raised in the first denial, but also expand your clinical reasoning. Sometimes the first reviewer missed something obvious, but you need to make it impossible for the second reviewer to miss it too.

For particularly complex cases, consider bringing in specialist consultation notes or additional testing results that support your position. Aetna's medical directors generally respect input from specialists in relevant fields.

One strategy that's worked well for me: if you're dealing with a pattern of denials for similar services, compile data on your approval rates and present it as part of your appeal. Aetna doesn't want to appear arbitrary, and showing inconsistency in their decision-making can be powerful.

There are also some newer AI-powered appeal generation tools that can help streamline the writing process and ensure you're hitting all the key points Aetna looks for. While I still recommend reviewing and personalizing any AI-generated content, these tools can be particularly helpful for practices handling high volumes of appeals.

Moving Forward: Building a Better Relationship

Here's something most practices don't think about: Aetna actually tracks your appeal success rates and overall relationship quality. Practices that consistently submit well-documented claims and professional appeals tend to get better treatment over time.

Keep detailed records of your appeals – what worked, what didn't, and which reviewers were particularly helpful or difficult. This intelligence becomes invaluable for future cases. Create templates for your most common appeal scenarios, but always customize them for the specific case.

Consider assigning appeal responsibilities to specific staff members who can develop expertise with Aetna's quirks and preferences. Having someone who knows exactly how to navigate their phone system or understands which documentation they prioritize can save hours of frustration.

The bottom line? Aetna appeals are absolutely winnable when you approach them strategically. Focus on clear communication, solid clinical reasoning, and persistence when you know you're right. Your success rate – and your sanity – will thank you for it.