Aetna Denied Your Physical Therapy?
Published data shows denial and appeal outcomes vary by plan, product year, denial reason, and documentation. Use this page to spot the issues to request and the evidence to gather before you decide what to submit.This template provides issues to verify, not insurer-specific outcome or deadline predictions. Your denial notice, current plan document, claim status, and governing program control.
Deadlines and review routes depend on plan type, urgent or standard status, whether care has already occurred, jurisdiction, and review level. Use the dates and instructions in the denial notice and current plan documents.
Why they said no
Common reasons Physical Therapy claims are denied
Visit limit exceeded per plan year
Maintenance therapy — no longer improving
Prior authorization expired or not renewed
Aetna checks
Issues to check in the Aetna notice
A "not medically necessary" finding — ask which records the reviewer actually had and which written criteria were applied
Step-therapy requirements — check whether the plan credited treatments you already tried and documented
For Medicare Advantage, criteria that may differ from applicable Medicare rules — compare the cited policy with the current NCD, LCD, or permitted public internal criteria
What works
How to Strengthen Your Physical Therapy Appeal
Objective measurement of functional progress (ROM, strength, balance scores)
Treatment plan with specific, measurable goals
Documentation that cessation would cause regression
For Medicare: cite the Jimmo v. Sebelius settlement, which clarifies that improvement is not required for coverage — skilled care to maintain function or slow decline can be covered when all other coverage requirements are met
Rules to verify
Rights and coverage rules that may apply
The plan’s rehabilitation benefit, visit limits, and authorization rules — coverage varies by product and setting
Jimmo settlement principles — for Medicare, lack of improvement cannot be the sole reason to deny otherwise-covered skilled care; all other coverage requirements still apply
State rehabilitation mandates — apply only to specified services and state-regulated plans
Playbook
Tips for Appealing to Aetna
Request the specific clinical criteria used to deny your claim
Ask for a peer-to-peer review between your doctor and their medical director
If the internal appeal fails, external review or a regulator complaint may be an option — a state-regulated plan goes to your state insurance department; a self-funded employer (ERISA) plan is overseen by the U.S. Department of Labor (EBSA), not the state
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Related denial guides
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Physical Therapy denials by other insurers
This information is for educational and informational purposes only. It does not constitute legal or medical advice. This page cites no statistics; it lists issues to verify against your own denial notice, plan documents, and the governing rules. Individual results vary. Consult a qualified professional before taking action on your specific situation.