Npwt denied for failing step therapy by Aetna?

Aetna's specific coverage criteria for npwt 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 NPWT Under Step Therapy — and How to Challenge It

Step therapy for wound care means Aetna requires documentation that simpler, less expensive wound management strategies were tried and failed before approving negative pressure wound therapy (NPWT). A step-therapy denial does not mean NPWT is inappropriate — it means the submission did not adequately document the prior treatment history. If your provider moved to NPWT based on sound clinical judgment after less advanced care proved insufficient, the record almost certainly contains the evidence needed to overturn this denial.

## Your Federal Appeal Rights

• Internal appeal (ACA §2719 / ERISA §503): A full-and-fair review must be offered. File your appeal within the deadline on the denial notice.
• Step-therapy exception: Many states have step-therapy exception laws requiring insurers to waive the step requirement when prior therapy has already failed, when it would be contraindicated, or when delay would harm the patient. Check whether your state's protections apply.
• External review: Available after internal appeals are exhausted, generally within approximately four months of a final adverse determination.
• Expedited review: Available when clinical urgency makes standard timelines inappropriate.

## Concrete Appeal Steps

1. Pull Aetna's published step-therapy or prior-authorization policy for NPWT to identify exactly what prior therapies are required. 2. Compile the complete wound care treatment history from the medical record. 3. Have the prescribing clinician write a letter documenting each step-therapy requirement, the therapy attempted, the dates, and the clinical outcome. 4. If a required step would have been clinically inappropriate, have the provider explain why.

## Documentation to Gather

• Prior wound care history: Every wound treatment attempted before NPWT, with start/end dates, products used, and documented outcome.
• Failure documentation: Chart notes, wound measurements, or photos showing inadequate response to prior treatment.
• Diagnosis confirmation: Wound type, etiology, and any complicating factors that affect healing.
• Clinical severity: Current wound status demonstrating the need to escalate to NPWT.
• Prescriber medical-necessity letter: Explicitly addresses each step in Aetna's protocol and explains why NPWT is now the appropriate next step.

## Criteria-Mapping Structure

Obtain Aetna's NPWT step-therapy criteria. List each required prior therapy in one column. In the next column, cite the exact chart entry showing that therapy was tried — the date, the clinician's note, and the documented result. If a step was skipped for a legitimate clinical reason, document that reason explicitly. Reference the applicable wound care guideline organization generically to support the clinical basis for escalating to NPWT at this stage.