LVAD DT denied for failing step therapy by Aetna?

Aetna's specific coverage criteria for lvad dt 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 Applied Step Therapy to Your LVAD Destination Therapy — And Why You Can Appeal

Step therapy — the requirement to try and fail certain treatments before a requested therapy is approved — is a common managed-care cost-control tool. When applied to LVAD destination therapy, a step-therapy denial typically means Aetna's policy requires documentation that the patient has undergone and failed an adequate trial of guideline-directed medical therapy (GDMT) before surgical implantation is considered. This is also called a "fail-first" requirement.

This type of denial is very commonly appealed successfully, because most patients who have reached the point of LVAD candidacy have in fact completed extensive prior therapy — the documentation simply was not submitted in a way that satisfied Aetna's specific criteria.

## Why This Denial Is Appealable

If your medical record contains evidence that prior steps were completed — even if not labeled as such in the original authorization request — your appeal can present that documentation in the structured format Aetna requires. Additionally, if your cardiologist believes that completing the required prior step would be clinically harmful, contraindicated, or medically unnecessary given your current condition, that clinical judgment can be documented and submitted as grounds for a step-therapy exception.

## Federal Appeal Framework

• Internal appeal: File within the timeframe in the denial letter. Expedited review (72-hour turnaround) is available for urgent cardiac situations.
• External review (ACA §2719): Available after a final internal denial, generally within a four-month window. The external IRO evaluates whether step-therapy application was clinically appropriate.
• Expedited external review: Available simultaneously with expedited internal appeal when the situation is urgent.
• ERISA §503: Employer-sponsored plans must allow a full-and-fair review of all evidence, including new documentation.
• State step-therapy laws: Many states have enacted step-therapy exception laws requiring insurers to grant exceptions when prior steps are clinically inappropriate; confirm whether your state's law applies to your plan type.

## Documentation to Gather

• Comprehensive medication history: a chronological list of all heart failure medications tried, with start dates, titration history, outcomes, and reason for discontinuation or failure — demonstrating that GDMT was optimized
• Clinical response records: chart notes, lab results, and functional assessments showing how the patient responded (or failed to respond) to each prior therapy
• Cardiology notes: documenting the clinical decision-making process that led to LVAD candidacy
• Exception justification (if applicable): a letter from the cardiologist or cardiac surgeon explaining why any untried prior step would be medically inappropriate for this patient
• Aetna's coverage policy: identify each step requirement and match it directly to the patient's history

## Criteria-Mapping Structure

For each step Aetna's policy requires, write a paragraph citing the specific chart evidence that the step was completed (or explaining the clinical basis for the exception). Attach all referenced records as labeled exhibits. A well-organized, criteria-mapped appeal significantly improves the likelihood of reversal.