PrEP Apretude LA denied as not medically necessary by Aetna?

Aetna's specific coverage criteria for prep apretude la 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 Apretude (Long-Acting Cabotegravir) as Not Medically Necessary — and How to Appeal

Apretude (cabotegravir extended-release injectable suspension) is an FDA-approved long-acting injectable for HIV pre-exposure prophylaxis (PrEP). A medical-necessity denial from Aetna means the plan's reviewer concluded that your clinical documentation did not sufficiently establish that injectable PrEP — as opposed to oral PrEP — is appropriate for you. The appeal needs to demonstrate, using your specific chart evidence, that you meet Aetna's published criteria for this agent. This is a winnable appeal when the documentation is complete.

## Why This Denial Is Appealable

Medical-necessity determinations must be made on the basis of your individual clinical circumstances, not generic population-level assumptions. If your prescriber has determined that injectable long-acting PrEP is appropriate for you — and that determination is documented in the chart — Aetna's denial is a reviewable disagreement, not a final answer. Federal law entitles you to have that disagreement reviewed by an independent clinician.

## Your Federal Appeal Rights

• ACA §2719 / ERISA §503 — Non-grandfathered commercial and employer-sponsored plans must provide full-and-fair internal appeal and independent external review.
• External review window — Typically approximately four months from the date of the adverse benefit determination. Track this deadline.
• Expedited review — If delay in initiating or continuing PrEP poses a serious clinical risk, expedited review (typically 72 hours) is available.

## Concrete Appeal Steps

1. Obtain Aetna's clinical criteria for Apretude coverage — the current clinical policy bulletin, available on Aetna's website or by request. 2. Review the criteria with your prescriber — Identify every requirement and confirm your chart documents each one. 3. File a Level 1 internal appeal — Submit a prescriber medical-necessity letter that maps each policy criterion to a specific chart finding. 4. Request a peer-to-peer review — Your prescriber's direct conversation with Aetna's medical director is often decisive at this stage. 5. Escalate to external review if the internal appeal is denied.

## Documentation to Gather

• Prescriber medical-necessity letter — this is the most important document. It should address each of Aetna's stated criteria individually, citing chart dates and findings.
• HIV testing records confirming ongoing HIV-negative status.
• Documentation of PrEP candidacy — clinical notes addressing exposure risk and the basis for PrEP recommendation.
• Adherence history or documented adherence barriers for oral PrEP, if the clinical rationale for injectable PrEP relates to adherence.
• Current Aetna clinical policy bulletin for Apretude — obtain the exact version, note every criterion, and ensure your letter addresses each one.
• Applicable guideline organization recommendation — your prescriber may reference the relevant infectious disease or public health guideline body's position on long-acting injectable PrEP without citing specific statistics.

## Criteria-Mapping Structure

Copy each criterion from the Aetna policy bulletin verbatim. Beneath each criterion, write one sentence identifying the chart note, date, and clinician whose documentation satisfies it. Submit this as a structured exhibit to your appeal letter. Reviewers who receive a criterion-by-criterion map approve appeals at substantially higher rates than those receiving narrative-only submissions.