How to appeal an Aetna melanoma & melanoma-immunotherapy 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 melanoma & melanoma-immunotherapy

Cited policy: Aetna CPB on Opdivo + Yervoy Combination for Melanoma

Unresectable/metastatic melanoma. Induction nivo 1 mg/kg + ipi 3 mg/kg q3wk x 4, then nivo maintenance. Age ≥12 yr (pediatric label expanded). ECOG 0-1 preferred. Baseline labs: CBC, CMP, TFTs, cortisol, LDH, brain MRI. No active autoimmune disease, no prior grade 3+ irAE, no organ transplant.

How Aetna denies melanoma & melanoma-immunotherapy — and how to counter it

Where Aetna pushes back: 1) Combo too toxic — try Opdivo mono first; 2) PD-L1 high — mono sufficient; 3) Asymptomatic brain mets — not appropriate.

Counter-arguments that hold up: CheckMate-067 6.5-yr (Wolchok NEJM 2022): combo OS 49%, Opdivo 42%, Yervoy 23% — combo benefit durable, particularly in high-LDH, BRAF-mut, low-PD-L1, brain-met subgroups. CheckMate-204 (Tawbi NEJM 2018) — combo intracranial response 55% in asymptomatic brain mets. NCCN v3.2024 lists combo as preferred for high-risk Stage IV. Grade 3-4 irAEs ~59% but treatment-related mortality <0.5% with steroid/infliximab algorithms.

What Aetna typically denies for melanoma & melanoma-immunotherapy

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

• Keytruda (pembrolizumab)
• Opdivo (nivolumab) mono
• Yervoy (ipilimumab)
• Opdivo + Yervoy combo
• Opdualag (nivo+rela)
• Tafinlar + Mekinist

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.