How to appeal an Aetna genetic testing 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 genetic testing

Cited policy: Aetna Clinical Policy Bulletin (Genetic Testing) + Aetna Clinical Policy Bulletin (BRCA Testing) + Aetna Clinical Policy Bulletin (Genetic Counseling)

Detailed per-syndrome criteria in CPB 0140; close to NCCN; requires genetic counseling pre-test.

How Aetna denies genetic testing — and how to counter it

Where Aetna pushes back: 1) 'Prior genetic counseling by qualified provider not documented'; 2) 'Does not meet CPB 0140 criteria'; 3) 'Expanded carrier screening — only ACOG-tier conditions covered' (older); 4) 'VUS follow-up testing investigational'; 5) 'PGx panel — only single-gene with FDA labeling covered'.

Counter-arguments that hold up: Document GC by ABGC-certified counselor or boarded geneticist (telegenetics counts). ACOG #691 — pan-ethnic ECS is acceptable standard of care. USPSTF B-rec → ACA preventive coverage without cost-sharing. PGx single drug-gene pair: cite CPIC guideline + FDA label (DPYD/5-FU, TPMT/thiopurines, CYP2C19/clopidogrel boxed warning).

What Aetna typically denies for genetic testing

Across Aetna's commercial and Medicare books, denials cluster around a small number of patterns. For genetic testing, 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 genetic testing treatments most often flagged for prior auth, step therapy, or medical necessity review:

• Hereditary cancer panel
• BRCA1/2
• Lynch panel
• Cardiogenetic
• WES / WGS
• Carrier screening

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.