How to appeal an Aetna neuropsychological & psychological testing — adhd, tbi, dementia, asd, presurgical eval 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 neuropsychological & psychological testing — adhd, tbi, dementia, asd, presurgical eval

Cited policy: Aetna Clinical Policy Bulletin Neuropsychological and Psychological Testing

Diagnostic uncertainty after standard psychiatric / pediatric evaluation; results will guide treatment; symptoms in 2+ settings; co-occurring conditions to be ruled out (mood, anxiety, learning disorder, sleep disorder).

How Aetna denies neuropsychological & psychological testing — adhd, tbi, dementia, asd, presurgical eval — and how to counter it

Where Aetna pushes back: 1) 'Self-pay required for ADHD' — ADHD considered diagnosable by clinical interview alone; 2) Step therapy through clinical interview not exhausted; 3) 'Investigational' for adult ADHD batteries.

Counter-arguments that hold up: AAP Clinical Practice Guideline (Wolraich Pediatrics 2019) supports comprehensive eval when diagnostic uncertainty + co-occurring conditions + 2-setting documentation. DSM-5-TR requires multi-informant data. Adult ADHD: DIVA-5 (Kooij), CAARS (Conners), Wender Utah Rating Scale are validated standards. ERISA MHPAEA: more restrictive medical-necessity criteria for mental-health testing than for comparable medical/surgical workup is a parity violation (Wit v. UBH). Submit DIVA-5 / CAARS scores + functional impairment documentation (work, home, school).

What Aetna typically denies for neuropsychological & psychological testing — adhd, tbi, dementia, asd, presurgical eval

Across Aetna's commercial and Medicare books, denials cluster around a small number of patterns. For neuropsychological & psychological testing — adhd, tbi, dementia, asd, presurgical eval, 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 neuropsychological & psychological testing — adhd, tbi, dementia, asd, presurgical eval treatments most often flagged for prior auth, step therapy, or medical necessity review:

• Comprehensive neuropsych battery
• ADHD neuropsych eval
• Post-concussion / mTBI eval
• Moderate-severe TBI eval
• Dementia workup
• ASD diagnostic eval

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.