Denied by Aetna or CVS Health across Commercial, Medicare Advantage, or Medicaid plans? You have federally protected rights under ERISA and the ACA. ClaimBack writes your professional appeal letter in 3 minutes.
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As one of the largest US insurers with 22 million members, Aetna is subject to robust federal and state oversight. Here's what you need to know.
Aetna is regulated by your State Department of Insurance (DOI) for commercial plans and by the Centers for Medicare & Medicaid Services (CMS) for Medicare Advantage plans. Your state DOI has authority to investigate unfair claim practices and can sanction Aetna for improper denials. CMS sets strict standards for Medicare Advantage plan conduct.
If your plan is employer-sponsored, ERISA gives you the right to a full and fair review of any denied claim. The ACA mandates external review rights for all non-grandfathered health plans. You are entitled to a written explanation for every denial, the clinical criteria used, and the specific plan provision that was applied. Aetna must provide this information upon request.
Internal appeal: Aetna must decide urgent care appeals within 72 hours, pre-service appeals within 30 days, and post-service (claims) appeals within 60 days. External review: Once you request external review, an independent organization has 45 days to issue a decision (or 72 hours for urgent cases). The external reviewer's decision is binding on Aetna.
Studies show that 60–80% of insurance appeals succeed when supported by proper medical documentation and a well-structured appeal letter. Most people never appeal — fewer than 1% of denied claimants formally challenge their denial. A professionally drafted appeal letter citing the correct clinical and regulatory criteria dramatically increases your chances of overturning an Aetna denial.
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ClaimBack provides AI-assisted document drafting. We are not a law firm and do not provide legal advice.