Hyperbaric Oxygen denied as duplicate or overlapping therapy by Aetna?

Aetna's specific coverage criteria for hyperbaric oxygen 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 Hyperbaric Oxygen as "Duplicate Therapy" — and How to Appeal

A duplicate therapy denial for hyperbaric oxygen therapy (HBOT) typically arises when Aetna's claims system detects that another treatment for the same condition is currently active — for example, wound care, antibiotics, or another oxygen-delivery modality — and flags HBOT as redundant. This is almost always an inappropriate denial when HBOT is being used as an adjunct treatment, because HBOT works through a distinct physiological mechanism and is not interchangeable with the other therapies on file.

The key to overturning this denial is demonstrating that HBOT is complementary, not duplicative: it addresses a different aspect of treatment, and its removal or substitution would leave a gap that the "duplicate" therapy cannot fill.

## Your Federal Appeal Rights

• Internal appeal: Aetna must provide a full-and-fair review under ERISA §503 and ACA §2719. File your written appeal within the timeframe on your denial letter (typically 180 days from denial).
• External review: If internal appeal fails, ACA §2719 provides access to an Independent Review Organization (IRO). You generally have four months (180 days) from the final adverse determination.
• Expedited review: For urgent situations — such as a non-healing wound at risk of infection or limb loss — request expedited internal and external review simultaneously. Aetna must respond to an expedited internal appeal within 72 hours.

## Documentation to Gather

1. Prescriber medical-necessity letter — a letter from your treating physician explicitly explaining how HBOT differs mechanistically from the other therapies on file and why both are necessary concurrently. 2. Treatment plan documentation — the full care plan showing all current treatments, their goals, and how each addresses a distinct element of the clinical picture. 3. Diagnosis and clinical severity — chart notes confirming the diagnosis, the severity of the condition, and any indicators (such as wound characteristics or imaging) that support multi-modal treatment. 4. Relevant guideline organization support — reference to applicable specialty society guidance (e.g., from the Undersea and Hyperbaric Medical Society) establishing HBOT as an adjunct, not a standalone replacement, for the condition. 5. Aetna's duplicate-therapy policy — request the exact criteria Aetna uses to define duplicate therapy, then address each point.

## Criteria-Mapping Structure

Address the duplication argument directly: "Aetna identifies therapy X as a duplicate. Rebuttal: HBOT operates via [mechanism per prescriber letter]; therapy X operates via [mechanism per prescriber letter]; the two address different aspects of treatment as documented in the care plan dated [date]." A side-by-side comparison in your appeal letter is particularly effective for this denial type.