How to appeal an Aetna neurology — alzheimer's, parkinson's, als, epilepsy 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 neurology — alzheimer's, parkinson's, als, epilepsy

Cited policy: Aetna Clinical Policy Bulletin — Aducanumab/Lecanemab/Donanemab

Confirmed early AD, biomarker+, ARIA risk counseling, MRI surveillance. Anticoagulation contraindications.

How Aetna denies neurology — alzheimer's, parkinson's, als, epilepsy — and how to counter it

Where Aetna pushes back: 1) 'Investigational' label on older bulletins; 2) Step therapy through donepezil/rivastigmine first; 3) Anticoagulation precludes use.

Counter-arguments that hold up: Cite FDA traditional approval (Leqembi Jul 2023, Kisunla Jul 2024). Clarity-AD / TRAILBLAZER-ALZ 2 results. Cholinesterase inhibitors are symptomatic — different mechanism — not interchangeable with disease-modifying anti-amyloid. Anticoagulation is relative contraindication; document risk-benefit + careful surveillance plan.

What Aetna typically denies for neurology — alzheimer's, parkinson's, als, epilepsy

Across Aetna's commercial and Medicare books, denials cluster around a small number of patterns. For neurology — alzheimer's, parkinson's, als, epilepsy, 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 neurology — alzheimer's, parkinson's, als, epilepsy treatments most often flagged for prior auth, step therapy, or medical necessity review:

• Leqembi
• Kisunla
• Rytary / Crexont
• Ongentys / Gocovri
• Inbrija
• Onapgo

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.