How to appeal an Aetna inpatient rehab — irf / snf / ltac admission and length-of-stay 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 inpatient rehab — irf / snf / ltac admission and length-of-stay

Cited policy: Aetna Clinical Policy Bulletin Skilled Care (covers SNF, home health, and outpatient skilled therapy)

Daily skilled service required: skilled nursing OR skilled therapy. 3-day qualifying acute hospital stay (Medicare). Skilled service must require the skills of licensed personnel. Maintenance therapy IS skilled per Jimmo when complexity warrants; improvement is NOT required.

How Aetna denies inpatient rehab — irf / snf / ltac admission and length-of-stay — and how to counter it

Where Aetna pushes back: 1) 'No improvement / maintenance therapy not covered' (incorrect post-Jimmo); 2) 'Skilled service can be performed by non-skilled personnel'; 3) '3-day qualifying stay missing'; 4) 'Custodial care, not skilled'.

Counter-arguments that hold up: Cite Jimmo v. Sebelius (2013) settlement — Medicare cannot deny SNF based on lack of improvement; maintenance therapy IS skilled when complexity requires qualified personnel. CMS Manual Ch. 8 §30.2.2 (post-Jimmo revision, CR 8458) explicitly removes the improvement standard. Submit skilled service log: IV antibiotics, complex wound care (NPWT, multiple stages), G-tube/NG management, complex diabetes management, complex pain management, skilled PT/OT/SLP for restoration OR maintenance. Document 3-day qualifying inpatient stay (NOT observation) with admit and discharge dates.

What Aetna typically denies for inpatient rehab — irf / snf / ltac admission and length-of-stay

Across Aetna's commercial and Medicare books, denials cluster around a small number of patterns. For inpatient rehab — irf / snf / ltac admission and length-of-stay, 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 inpatient rehab — irf / snf / ltac admission and length-of-stay treatments most often flagged for prior auth, step therapy, or medical necessity review:

• IRF admission
• IRF length-of-stay
• SNF admission
• SNF length-of-stay
• LTAC admission
• LTAC length-of-stay

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.