Aetna Denied Your Rehabilitation / PT / OT?
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 Rehabilitation / PT / OT claims are denied
Maximum therapy visits reached for the year
Not making sufficient progress toward goals
Treatment deemed maintenance rather than restorative
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 Rehabilitation / PT / OT Appeal
Therapist documentation of measurable functional improvement
Updated treatment plan with specific, measurable goals
Physician letter explaining medical necessity of continued therapy
Rules to verify
Rights and coverage rules that may apply
The plan’s rehabilitation or habilitation benefit — visit limits, settings, and authorization requirements remain plan-specific
Jimmo settlement principles — for Medicare, improvement potential cannot be the sole test for otherwise-covered skilled care
ACA or state mandates — apply only to specified services and regulated plan types; verify the actual plan document
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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Rehabilitation / PT / OT 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.