Aetna Denied Your Physical Therapy?
Aetna (CVS Health) denies 16.7% of claims on average. But 49% of appeals succeed when patients fight back. Your physical therapy denial may have grounds for a successful appeal.
Why Aetna Denies Physical Therapy
Visit limit exceeded per plan year
Maintenance therapy — no longer improving
Prior authorization expired or not renewed
Aetna's Common Denial Tactics
Citing lack of medical necessity without reviewing full records
Applying step therapy requirements retroactively
Using internal guidelines stricter than Medicare standards
How to Win 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 Jimmo v. Sebelius settlement requiring maintenance coverage
Laws That Protect You
ACA §2719 — Appeal rights
Jimmo v. Sebelius (Medicare) — Maintenance therapy coverage
State mandated minimums for PT visits
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
File with your state insurance department if internal appeal fails
Ready to Fight Your Physical Therapy Denial?
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This information is for educational and informational purposes only. It does not constitute legal or medical advice. Statistics cited are from publicly available sources including KFF, HHS OIG, and state insurance department data. Individual results may vary. Consult a qualified professional before taking action on your specific situation.