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.
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. Switching the prescription path to a T2D-approved molecule (Ozempic, Mounjaro) when comorbidities exist often produces a same-week reversal.
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 must be filed within 180 days. After internal denial, an external review by an Independent Review Organization (IRO) is available within 60 days, a separately strong reversal lane.
Internal level 1 (30 days standard / 72h urgent), then external IRO review (45 days standard).
180 days from denial for internal appeal; 60 days from final internal denial for external review.
How we file Aetna appeals
Aetna's internal appeals respond well to peer-to-peer review requests filed alongside the written appeal.
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