How to appeal an Aetna glaucoma (drops + procedures + surgery) 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 glaucoma (drops + procedures + surgery)

Cited policy: Aetna Clinical Policy Bulletin: MIGS Devices (Hydrus Microstent CPT 0671T / 66989-66991)

Mild-to-moderate POAG, pseudoexfoliation, or pigmentary glaucoma. Visually significant cataract requiring concurrent phacoemulsification. IOP not controlled on tolerated topical therapy or documented intolerance. Open angle on gonioscopy. Concurrent cataract surgery (per FDA label).

How Aetna denies glaucoma (drops + procedures + surgery) — and how to counter it

Where Aetna pushes back: 1) MIGS labeled experimental / investigational; 2) MIGS only at time of cataract; 3) Prefer trabeculectomy first.

Counter-arguments that hold up: Hydrus Microstent FDA-approved Aug 2018 — NOT experimental. HORIZON pivotal RCT (Samuelson Ophthalmology 2019;126:29-37) — 24-mo primary endpoint 20% washed-out diurnal IOP reduction met in 77.3% Hydrus + phaco vs 57.8% phaco alone (p<0.001); medications reduced 1.7→0.3 vs 1.7→0.7. 5-yr durability (Ahmed 2022) sustained. AGS MIGS position 2020 endorses Hydrus in mild-moderate POAG. WGA 2017 consensus codifies trabecular bypass / Schlemm's-canal scaffold devices. Cite specific HORIZON data + FDA approval letter.

What Aetna typically denies for glaucoma (drops + procedures + surgery)

Across Aetna's commercial and Medicare books, denials cluster around a small number of patterns. For glaucoma (drops + procedures + surgery), 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 glaucoma (drops + procedures + surgery) treatments most often flagged for prior auth, step therapy, or medical necessity review:

• Latanoprost (generic)
• Xelpros (BAK-free latanoprost)
• Travatan Z (travoprost)
• Lumigan (bimatoprost)
• Zioptan (tafluprost PF)
• Vyzulta (LBN)

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.