Aetna Prior Authorization Denied: How to Appeal

Why Aetna Denies Prior Authorization Requests

Aetna denies prior authorization (PA) requests when it determines the requested service does not meet its internal clinical criteria for medical necessity, the request was submitted incorrectly, or the service requires a step-therapy protocol the insurer says was not followed.

Prior authorization denials are among the most common — and most overturnable — denials Aetna issues.

Common Denial Reasons

• Not medically necessary: Aetna's clinical reviewers determined the service does not meet its coverage criteria
• Missing or incomplete documentation: The PA request lacked required clinical notes or physician attestation
• Step therapy not completed: Aetna requires a cheaper alternative treatment to be tried first
• Wrong provider type: The requesting provider is not approved to perform the service
• Duplicate request: A prior authorization for the same service already exists or was previously denied

Steps to Appeal

1. Request the denial in writing — Aetna must provide a written denial with the specific clinical criteria it applied
2. Obtain the clinical policy bulletin — Request Aetna's internal policy document used to evaluate your request
3. Get a letter of medical necessity — Your treating physician should write a detailed letter addressing Aetna's specific denial reason
4. File an internal appeal — Submit within 180 days of the denial notice; urgent appeals must be processed within 72 hours
5. Request peer-to-peer review — Your physician can call Aetna's medical reviewer directly; many PA denials reverse at this stage
6. File for external review — If the internal appeal fails, request independent external review; Aetna must comply under ACA rules

Documents Required

• Original prior authorization denial letter
• Your physician's letter of medical necessity
• Supporting clinical records (office notes, test results, specialist referrals)
• Aetna's clinical policy bulletin for the denied service
• Published clinical guidelines supporting the treatment (AHA, NCCN, ADA, etc.)

Frequently Asked Questions

Q: How long does Aetna have to respond to a PA appeal? A: Standard appeals: 30 days. Urgent/expedited appeals: 72 hours. Concurrent review appeals: 30 days.

Q: Can Aetna deny my appeal without a doctor reviewing it? A: No. Under URAC accreditation standards and state law, Aetna's appeal must be reviewed by a clinician with relevant specialty expertise.

Q: What if my doctor already performed the service without authorization? A: You can request retrospective authorization. Aetna must review it on its clinical merits. If the service was medically necessary, it should be approved retroactively.