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Insurer Playbook

Aetna (CVS Health)

Also known as: Aetna, CVS Aetna, CVS Health

EmployerIndividualMedicare AdvantageMedicaid

4

Known denial patterns

4

Appeal best practices

3

Known weaknesses

Common Denial Patterns

  • Medical necessity denials citing Clinical Policy Bulletins
  • Step therapy enforcement for specialty medications
  • Prior authorization denials for outpatient procedures
  • Behavioral health denials (check Mental Health Parity)

Appeal Best Practices

  1. 1Reference the specific Aetna CPB number and section
  2. 2Include clinical guidelines that differ from Aetna criteria
  3. 3For behavioral health denials, explicitly cite MHPAEA
  4. 4Request the qualifications of the reviewer who denied the claim

Known Weaknesses

  • CPBs can be more restrictive than clinical consensus — cite broader evidence
  • Behavioral health reviews may not meet Mental Health Parity requirements
  • Aetna merged with CVS — pharmacy benefits may have conflicts of interest for drug denials

Contact & Response

Best Contact Method

Member portal > Fax > Mail

Typical Response Time

30 days (internal), 45 days (external)

Internal Criteria Used

  • Aetna Clinical Policy Bulletins (CPBs)
  • MCG

General Tips

  • Aetna publishes Clinical Policy Bulletins (CPBs) — reference the specific CPB
  • Aetna uses both MCG and internal criteria for medical necessity
  • Online appeal submission available through member portal
  • Aetna has a dedicated clinical appeals team
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This information is for educational purposes based on publicly available data including CMS reports, state insurance department filings, and published insurer guidelines. It does not constitute legal, medical, or financial advice. Individual results vary. Verify all information independently and consult qualified professionals before acting.