How to appeal an Aetna migraine cgrp inhibitors 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 migraine cgrp inhibitors

Cited policy: Aetna Clinical Policy Bulletin - Calcitonin Gene-Related Peptide (CGRP) Antagonists

Diagnosis of migraine per ICHD-3; >=4 MMD; trial+inadequate response, intolerance, or contraindication to >=2 preventive medications from different classes for >=2 months each.

How Aetna denies migraine cgrp inhibitors — and how to counter it

Where Aetna pushes back: 1) 'Experimental/investigational' framing for Zavzpret, Vyepti; 2) 'Not meeting MMD threshold' when documentation shows 3 MMD; 3) Combination therapy denials.

Counter-arguments that hold up: CPB 0697 itself accepts contraindication as equivalent to failure — cite specific contraindication (cardiac for propranolol, cognitive for topiramate). HIT-6 >=60 to support disability. AHS 2021 update lowering threshold.

What Aetna typically denies for migraine cgrp inhibitors

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

• Aimovig
• Ajovy
• Emgality
• Vyepti
• Qulipta
• Nurtec ODT

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.