How to appeal an Aetna long covid / pasc 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 long covid / pasc

Cited policy: Aetna Clinical Policy Bulletin — Hyperbaric Oxygen Therapy

Lists FDA-cleared HBOT indications (decompression sickness, gas embolism, CO poisoning, gas gangrene, crush injury, refractory osteomyelitis, late radiation tissue injury, diabetic foot ulcers Wagner >=3). PASC NOT listed — appeal route is 'off-label with peer-reviewed evidence' exception.

How Aetna denies long covid / pasc — and how to counter it

Where Aetna pushes back: 1) PASC not on FDA-cleared list; 2) Experimental for Long COVID; 3) Insufficient evidence.

Counter-arguments that hold up: Cite Zilberman-Itskovich Sci Reports 2022 RCT n=73 — significant cognitive + fatigue improvement vs sham. Off-label use is NOT the same as experimental — supported by peer-reviewed RCT evidence. Request 'medically necessary off-label' exception under ACA appeal rights. Document failure of standard cognitive rehab + PT-induced harm if applicable.

What Aetna typically denies for long covid / pasc

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

• Multidisciplinary clinic
• Cognitive rehab
• PEM-aware PT / pacing
• Tilt-table / stand test
• POTS pharmacotherapy
• MCAS treatment

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.