How to appeal an Aetna cardiology drugs denial

The framework that applies to your appeal

Federal law gives you the right to a full and fair internal appeal, then an external review by an independent third party.

Aetna-specific note: Owned by CVS Health since 2018. CVS Caremark is the PBM. Aetna ASA administers self-funded ERISA plans. Meritain Health is Aetna's TPA brand.

What Aetna's policy requires for cardiology drugs

Cited policy: Aetna Clinical Policy Bulletin — Tafamidis (Vyndaqel/Vyndamax)

Confirmed ATTR-CM: PYP scintigraphy grade 2-3 cardiac uptake AND negative monoclonal screen (SPEP+IFE+serum/urine IFE+sFLC) AND TTR genotype. NYHA I-III at baseline.

How Aetna denies cardiology drugs — and how to counter it

Where Aetna pushes back: 1) AL amyloidosis not excluded; 2) PYP scan H/CL ratio not stated; 3) TTR genotype not provided.

Counter-arguments that hold up: Provide complete diagnostic workup on one page: PYP H/CL ratio + Perugini grade + IFE/sFLC negativity + TTR genotype. Cite Maurer 2019 ATTR algorithm + ATTR-ACT NEJM 2018 (30% mortality reduction).

What Aetna typically denies for cardiology drugs

Across Aetna's commercial and Medicare books, denials cluster around a small number of patterns. For cardiology drugs, expect:

• UM-2575 medical necessity denials
• Prior auth absent
• Step therapy on specialty drugs
• Out-of-network ER reduction

Treatments most often denied in this category

These are the cardiology drugs treatments most often flagged for prior auth, step therapy, or medical necessity review:

• Repatha
• Praluent
• Leqvio
• Entresto
• SGLT2i for HF
• Verquvo

How to submit the appeal to Aetna

1. Read the denial letter — note the exact denial reason code and the appeal deadline (180 days from the date on the letter).
2. Gather supporting documentation: physician letter of medical necessity, relevant clinical notes, peer-reviewed citations supporting the treatment for your indication, and the policy or coverage document Aetna cited in the denial.
3. File the appeal through Aetna's portal (members: https://www.aetna.com ; providers: https://www.aetnaprovider.com). Standard decision returns within 30 days; expedited urgent appeals return within 72 hours.
4. If denied again, request external review by an independent reviewer within 4 months of the final internal denial. In CT, the state insurance department coordinates external review for fully-insured plans; ERISA self-funded plans use a federal external review through DOL/EBSA.

Clinician or prior-auth team handling this on the practice side? See Aetna's prior-authorization criteria by drug: Aetna PA criteria on ApprovalHelp.