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Insurer Playbook

Aetna (CVS Health)Denial patterns and how to appeal

Also known as: Aetna, CVS Aetna, CVS Health

EmployerIndividualMedicare AdvantageMedicaid

4

Known denial patterns

4

Appeal best practices

2

Points to check

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

Points to Check

  • Compare the Clinical Policy Bulletin (CPB) the denial cites with current clinical guidelines, and cite broader evidence where they differ
  • For behavioral health denials, check whether federal mental health parity rules apply to your plan

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

Built for Aetna (CVS Health)

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Lysco uses Aetna (CVS Health)-specific intelligence — denial patterns, appeal best practices, and the right contact path — to identify weak points and draft your appeal.

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This is general guidance compiled by Lysco. Check it against your plan documents and the notice you received, which set the rules for your appeal. It does not constitute legal, medical, or financial advice. Individual results vary. Verify all information independently and consult qualified professionals before acting.