How to appeal an Aetna hepatitis c cures 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 hepatitis c cures

Cited policy: Aetna Clinical Policy Bulletin - Hepatitis C Antiviral Agents (Caremark Hepatitis C Agents PA)

RNA-confirmed HCV; genotype; fibrosis or pangenotypic regimen; prescriber attestation re: adherence.

How Aetna denies hepatitis c cures — and how to counter it

Where Aetna pushes back: 1) 6 months documented sobriety required; 2) Fibrosis F2 or higher required; 3) Quantity limit / 8-wk Mavyret denied, 12-wk required.

Counter-arguments that hold up: AASLD/IDSA verbatim: 'Active or recent drug use or a concern for reinfection is not a contraindication to HCV treatment.' Sobriety mandates contradict guidance, are NOT supported by SVR data (PWID achieve equivalent SVR12), undermine elimination goal. Treat-all per AASLD. CMS Notice CPI-MM-2015-01 (Nov 2015). B.E. v. Teeter precedent. 8-wk Mavyret in TN non-cirrhotic FDA-approved AND AASLD-preferred (ENDURANCE-1/-3 demonstrated 99%+ SVR12).

What Aetna typically denies for hepatitis c cures

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

• Mavyret 8wk
• Mavyret 12-16wk
• Epclusa 12wk
• Epclusa+RBV
• Vosevi
• Harvoni

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.