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Aetna • Medical necessity

How to appeal a medical necessity denial from Aetna

Aetna issues medical-necessity denials under its Clinical Policy Bulletins (CPBs). The fastest path to overturn one is to map your chart line-by-line to the specific CPB Aetna cited on your denial letter.

Internal appeal: 180 days External review: 60 days

Step-by-step

  1. 1

    Pull the exact Clinical Policy Bulletin Aetna cited

    Your denial letter will name a CPB (e.g., CPB 0006). Find it on aetna.com/cpb - it lists the criteria the reviewer used. Print it and highlight every criterion.

  2. 2

    Get a letter of medical necessity from your provider

    Ask your provider to write the letter against the CPB you printed - each Aetna criterion gets a paragraph quoting your chart. This is the single highest-leverage document in the appeal.

  3. 3

    Submit the first-level internal appeal

    Mail or upload via the Aetna member portal. Include: denial letter, letter of medical necessity, full chart notes for the service, any imaging reports, and proof of conservative care tried.

  4. 4

    If denied, request a second-level appeal and peer-to-peer review

    Ask your provider to request a peer-to-peer with Aetna's medical director. These calls are short and frequently reverse denials when the original reviewer wasn't the right specialty.

  5. 5

    Request external review

    If both internal appeals fail, you have 60 days from the final denial to request an Independent Review Organization. Aetna must comply with the IRO decision.

Documents to gather

  • Original denial letter (all pages)
  • Aetna Clinical Policy Bulletin cited
  • Letter of medical necessity from treating provider
  • Full chart notes for the service in question
  • Imaging or lab reports
  • Documentation of prior conservative treatment

Decode your full denial letter

Paste or upload your Aetna letter and get the exact deadline, escalation ladder, and a ready-to-send appeal letter.

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Frequently asked questions

How long do I have to appeal an Aetna denial?
180 days from the date on the denial letter for the first internal appeal. Some employer plans shorten this - always check the appeal-rights section of your denial.
Does Aetna have to give me the reviewer's notes?
Yes. Under ERISA and ACA rules you can request the full claim file, the reviewer's notes, and the medical policy applied - Aetna must provide them at no charge.
Can my doctor appeal for me?
Yes, if you sign a designated-representative form. Provider-led appeals carry the clinical letter automatically and often move faster.

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