Aetna (CVS Health) denial appeals
Aetna, owned by CVS Health since 2018, runs commercial group plans, Medicare Advantage, and a large pharmacy benefit footprint via Caremark. GLP-1, specialty drug, and behavioral health denials are the highest-volume categories.
Aetna (CVS Health) reported claim denial rates, by state
In-network denial rate each Aetna (CVS Health) marketplace issuer reported to CMS (Transparency in Coverage PUF; two-year lag; includes administrative denials). Click a state for the full report card.
- ArizonaBanner Health and Aetna Health Plan Inc.22.1%
- DelawareAetna Health Inc. (a PA corp.)22.4%
- FloridaAetna Health Inc. (a FL corp.)22.3%
- GeorgiaAetna Health Inc. (a GA corp.)19.9%
- IllinoisAetna Health Inc. (a PA corp.)20.2%
- IllinoisAetna Life Insurance Companyn/a
- IndianaAetna Health Inc. (a PA corp.)n/a
- KansasAetna Life Insurance Companyn/a
- MissouriAetna Life Insurance Company19.1%
- North CarolinaAetna Health Inc. (a PA corp.)15.5%
- OhioAetna Health Inc. (a PA corp.)n/a
- TexasAetna Health Inc. (a TX corp.)27.3%
- UtahAetna Health of Utah Inc.n/a
If Aetna (CVS Health) denied a claim or service, you can appeal, and the plan must give you its file and the criteria it used. Filing windows by plan type: at least 180 days (employer self-funded plans); at least 180 days (insured and Marketplace plans); 65 days from the notice (Medicare Advantage); 65 days from the notice (Part D); 60 days from the notice (Medicaid managed care). The date printed on your denial notice controls; it can only be later than these floors, never earlier.
Aetna (CVS Health) appeals: the rule, the deadline and the next level, by plan type
Which row applies depends on the plan you hold, not on Aetna (CVS Health)'s brand. Your ID card, the Summary Plan Description and the denial letter say which.
| Plan type | Rule that governs | File your appeal within | The plan must answer | If the plan says no again |
|---|---|---|---|---|
| Employer self-funded plan (ERISA) Most large employers. The employer pays the claims and hires the carrier to administer them; the Summary Plan Description says self-funded or self-insured. | ERISA § 503 (29 U.S.C. § 1133) and the claims-procedure rule, 29 CFR 2560.503-1. Federal external review under 45 CFR 147.136(d) for non-grandfathered plans. | At least 180 days from the adverse benefit determination (29 CFR 2560.503-1(h)(3)(i)). | Urgent care: 72 hours. Pre-service: 30 days. Post-service: 60 days (29 CFR 2560.503-1(i)(2)). | Federal external review by an accredited independent review organization, requested within 4 months of the final internal denial (45 CFR 147.136(d)); then a civil action under ERISA § 502(a). State insurance departments do not regulate self-funded plans; the U.S. Department of Labor does. |
| Fully insured employer, individual or Marketplace plan The carrier holds the risk and is licensed in your state. Small employers and almost all individual and HealthCare.gov plans. | 45 CFR 147.136 (Public Health Service Act § 2719), which applies the 29 CFR 2560.503-1 procedures and adds state external review; state insurance law on top. | At least 180 days from the denial (45 CFR 147.136(b); 29 CFR 2560.503-1(h)(3)(i)). | Urgent care: 72 hours. Pre-service: 30 days. Post-service: 60 days. Prior-authorization decisions by Marketplace issuers from 2026: 72 hours expedited, 7 calendar days standard (CMS-0057-F). | External review through your state's process, or the federal process where the state has none, generally within 4 months of the final internal denial (45 CFR 147.136(c), (d)). The state insurance department and its Consumer Assistance Program take complaints. |
| Medicare Advantage (Part C) A private plan that replaces Original Medicare. The card says Medicare Advantage, HMO, PPO or PFFS. | 42 CFR Part 422, Subpart M (§§ 422.560 to 422.634). Coverage decisions must follow Original Medicare rules (42 CFR 422.101). | 65 calendar days from the date on the denial notice to request the plan's reconsideration (42 CFR 422.582, as amended effective 1 January 2025). | Expedited: 72 hours. Standard pre-service: 30 days (7 days for Part B drugs). Payment: 60 days (42 CFR 422.590). | If the plan does not fully reverse itself it must send the case to the Independent Review Entity on its own (42 CFR 422.592); then an ALJ hearing when the amount in controversy meets the annual threshold, the Medicare Appeals Council and federal court. State external review does not apply. |
| Medicare Part D (drug plan or MA-PD) A stand-alone drug plan or the drug benefit inside a Medicare Advantage plan. | 42 CFR Part 423, Subpart M; exceptions under 42 CFR 423.578. | 65 calendar days from the date on the notice to request a redetermination (42 CFR 423.582, as amended effective 1 January 2025). Formulary, tiering and step-therapy exceptions need the prescriber's supporting statement (§ 423.578). | Redetermination: 7 calendar days standard, 72 hours expedited (42 CFR 423.590). Coverage determinations: 72 hours standard, 24 hours expedited, once the prescriber's statement is received (§§ 423.568, 423.572). | Independent Review Entity reconsideration on your request within 65 days of the redetermination notice (§ 423.600); then ALJ, Council and court. |
| Medicaid managed care plan A Medicaid plan run by the carrier under a state contract. The card says Medicaid, Medi-Cal, STAR, HealthChoice or your state's programme name. | 42 CFR Part 438, Subpart F (plan appeals) and 42 CFR Part 431, Subpart E (state fair hearings). | 60 calendar days from the date on the notice of adverse benefit determination to request the plan's appeal (42 CFR 438.402(c)(2)(ii)). State fair hearing: within 120 calendar days of the plan's appeal decision (§ 438.408(f)(2)). | Standard appeal: 30 calendar days. Expedited: 72 hours (42 CFR 438.408(b)). | A state fair hearing after the plan's single level of appeal (§ 438.402(b)); some states add an external medical review. Benefits continue during the appeal if you ask within 10 calendar days of the notice (§ 438.420). |
What you can demand. The plan must give you the claim file, the internal rule or criterion it relied on, and the identity of the reviewer, free of charge, on request (29 CFR 2560.503-1(h)(2)(iii), (m)(8)).
How to open the appeal. Cite ERISA § 503 and 29 CFR 2560.503-1 in the opening paragraph: request the claim file and the specific criteria relied on, and note the 30-day (pre-service), 60-day (post-service) and 72-hour (urgent) decision clocks.
What you can demand. The plan must give you the claim file, the criteria it applied and any new evidence or rationale before the final decision, free of charge (45 CFR 147.136(b)(2)(ii)(C); 29 CFR 2560.503-1(h)(2)(iii)).
How to open the appeal. Cite 45 CFR 147.136 and 29 CFR 2560.503-1: request the claim file and the criteria, note the decision clocks, and name the state external-review right.
What you can demand. The plan may not apply internal criteria that are more restrictive than Medicare's national and local coverage determinations, and must decide medical necessity on your individual circumstances (42 CFR 422.101(b), (c)). You can ask for the case file and the criteria used.
How to open the appeal. Cite 42 CFR 422.582 and 422.101(c): the plan must decide on your individual circumstances under Medicare coverage rules, and must forward an unfavorable reconsideration to the IRE itself.
What you can demand. The exception turns on the prescriber's statement that the formulary alternative would be less effective or would harm you (42 CFR 423.578(b)(5)).
How to open the appeal. Cite 42 CFR 423.578 and 423.582 and attach the prescriber's supporting statement written to the exception standard.
What you can demand. Free copies of the case file, medical records and the criteria used, before and during the appeal (42 CFR 438.406(b)(5)). Children under 21 have EPSDT rights to medically necessary care (42 U.S.C. 1396d(r)(5)).
How to open the appeal. Cite 42 CFR 438.402 and 438.406(b)(5): request the case file and the criteria, ask for continued benefits within 10 days, and reserve the state fair hearing.
In the CMS Transparency in Coverage data for plan year 2026 (2024 claims), the 13 Aetna (CVS Health)-family Marketplace issuer filings across 12 states reported in-network claim denial rates from 15.5% to 27.3% (median 21.1%). Issuer-level, self-reported, HealthCare.gov plans only; a denial includes duplicate and administrative denials.
See every Aetna (CVS Health) issuer by state →Primary sources for this table
- 29 CFR 2560.503-1, ERISA claims procedure
- 45 CFR 147.136, internal claims and appeals and external review
- U.S. Department of Labor, EBSA, health benefit claims and appeals
- HealthCare.gov, how to appeal an insurance company decision
- CMS-0057-F, prior-authorization decision timeframes from 2026
- 42 CFR Part 422, Subpart M, Medicare Advantage grievances, organization determinations and appeals
- 42 CFR 422.101, Medicare Advantage coverage rules and medical-necessity decisions
- Medicare.gov, claims and appeals
- 42 CFR Part 423, Subpart M, Part D coverage determinations, redeterminations and reconsiderations
- 42 CFR 423.578, Part D exceptions process
- 42 CFR Part 438, Subpart F, Medicaid managed care grievance and appeal system
- 42 CFR Part 431, Subpart E, Medicaid fair hearings
Windows are federal floors or the rule as written; the denial notice controls. Reviewed 13 September 2026. General information, not legal advice; Apellica is not a law firm.
Patterns we see on Aetna denials
GLP-1 / Wegovy denials citing BMI
Aetna denies most weight-loss GLP-1 prescriptions citing BMI thresholds or 'lifestyle modification first' criteria. When a patient has documented comorbidities (such as type 2 diabetes) and the treating clinician determines a diabetes-indicated GLP-1 is medically appropriate, an appeal built on that documented clinical picture is often reversed quickly — the medication and indication remain the clinician's decision, never a path chosen simply to obtain coverage.
Caremark formulary denials
Aetna's pharmacy benefit (Caremark) issues formulary denials separate from medical benefit denials. Each requires its own appeal track, confusing the two costs weeks.
Internal appeal then external review
Aetna's first appeal is internal and is generally filed within 180 days of the denial. After a final internal denial, external review by an Independent Review Organization (IRO) is a separately strong reversal lane; under the federal ACA standard members generally have at least 4 months (120 days) to request it, though the exact window varies by plan and state — confirm the deadline printed on your denial letter.
Internal level 1 (30 days standard / 72h urgent), then external IRO review (45 days standard).
180 days from denial for internal appeal; generally at least 4 months (120 days) from the final internal denial for federal external review (exact window varies by plan and state — check your denial letter).
How we file Aetna appeals
Aetna's internal appeals respond well to peer-to-peer review requests filed alongside the written appeal.
Denied by Aetna? Let's appeal it.
Two-minute micro intake. We confirm fit and reply within one business day. No card at intake. You only pay if the carrier reverses the denial.
Start Your AppealDisclaimer: information shown is general guidance, not legal advice or a guarantee of outcome. Individual case outcomes depend on documentation, timing, and the specific terms of your plan.