BRCA Single Gene denied for missing prior authorization by Aetna?

Aetna's specific coverage criteria for brca single gene are defined in its own published medical/coverage policy and the FDA-approved prescribing label. A successful appeal documents that your medical records satisfy each criterion those sources list — confirmed diagnosis, any required prior treatments (with dates and outcomes), and clinical severity. If the exact criteria weren't included with your denial, request them in writing; your appeal then maps each requirement to the matching fact in your chart.

## Why Aetna Denied Your BRCA Single-Gene Test for Missing Prior Authorization

A prior-authorization (PA) denial means Aetna's records show no approved PA on file before the test was performed — or that the PA request was submitted but did not satisfy Aetna's criteria at the time. This is one of the most common and most successfully appealed denial types because the underlying clinical need is often well-documented; the gap is procedural rather than substantive.

## Your Federal Appeal Rights

• Internal appeal: File within the window shown on your Explanation of Benefits. For retrospective (post-service) PA denials, Aetna's internal review deadline is typically 60 days from the denial notice.
• External review (ACA §2719 / ERISA §503): Once Aetna issues a final adverse benefit determination, you have approximately four months to request independent external review. An independent organization — not Aetna — re-examines whether the denial was clinically and contractually appropriate.
• Expedited review: Available when delay would seriously jeopardize your health; decisions are typically rendered within 72 hours.

## Steps in the Appeal Process

1. Obtain the denial letter and Aetna's Clinical Policy Bulletin for hereditary BRCA testing. The policy will list the exact criteria PA reviewers apply. 2. Request a peer-to-peer review — your ordering clinician can speak directly with Aetna's medical director before or during the formal appeal; this resolves many PA denials without a full written appeal. 3. Submit a written appeal with supporting documentation if peer-to-peer is unsuccessful or unavailable.

## Documentation to Gather

1. Personal and/or family cancer history — chart notes, pathology reports, or family-history intake forms documenting the clinical rationale for testing. 2. Ordering clinician's medical-necessity letter — should map the patient's clinical profile to each criterion in Aetna's published policy. 3. Applicable guideline reference — the relevant NCCN or ACMG hereditary-cancer testing guideline, cited by name. 4. Any prior PA submission records — confirmation numbers, submission dates, and any communication from Aetna. 5. Proof of timely ordering — if the test was ordered in an urgent or inpatient context where PA was impractical, document that clinical context explicitly.

## Criteria-Mapping Structure

Pull Aetna's published Clinical Policy Bulletin and list every coverage criterion in a table. For each criterion, note the corresponding chart entry that satisfies it. Your clinician's letter should walk through this mapping row-by-row. If Aetna denied because PA was not obtained in advance, address why clinical circumstances required timely testing and attach any documentation showing that a PA request was attempted.

## Bottom Line

Prior-authorization denials for BRCA single-gene testing are frequently overturned on appeal when the clinical record clearly supports testing under the insurer's own published criteria. The key is demonstrating — criterion by criterion — that the test was medically necessary, not just that it was ordered.