PrEP Apretude LA denied for missing prior authorization 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) for Missing Prior Authorization — and How to Appeal

A prior authorization (PA) denial for Apretude means Aetna did not receive an approved PA request before the prescription was dispensed or the injection was administered. This is a procedural denial — it says nothing about whether Apretude is medically appropriate for you. Because PA denials are procedural, they are often resolved through a concurrent or retroactive authorization appeal, particularly when the underlying clinical criteria are met.

## Why This Denial Is Appealable

Federal law requires that PA denials be subject to individual clinical review through a full-and-fair appeal process. A retroactive or concurrent PA can often be approved when the clinical documentation demonstrates that the PA criteria were met at the time of prescribing — even if the authorization was not obtained in advance. Additionally, note that the ACA requires coverage of preventive services (including PrEP for eligible patients) without cost-sharing when delivered by in-network providers; consult your plan documents and applicable federal guidance to determine whether this requirement affects your situation.

## 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 for PA denials.
• External review window — Typically approximately four months from the adverse determination date. Track this deadline.
• Expedited review — If a pending injection appointment is being delayed and delay poses a clinical risk, request expedited processing (typically 72 hours).

## Concrete Appeal Steps

1. Determine whether a PA was submitted — Contact your prescriber's office and pharmacy to confirm whether a PA request was sent, when, and what response was received. Obtain any reference numbers. 2. Request retroactive authorization — Have your prescriber submit a retroactive PA with full supporting documentation simultaneously with the appeal. 3. File a Level 1 internal appeal — Submit the prescriber's medical-necessity letter and all supporting documentation, with a direct response to each PA criterion in Aetna's policy. 4. Invoke ACA preventive-services coverage if applicable — If your plan is subject to ACA preventive-services requirements, include a paragraph in your appeal letter addressing this. 5. Escalate to external review if internal appeals are denied.

## Documentation to Gather

• PA submission records from your prescriber's office or pharmacy — fax confirmations, portal submission records, phone call logs with Aetna reference numbers.
• Aetna PA criteria for Apretude — obtain the current clinical policy bulletin and identify every PA requirement.
• Prescriber medical-necessity letter addressing each PA criterion individually, with citations to specific chart notes and dates.
• HIV testing records confirming ongoing HIV-negative status and active PrEP candidacy.
• Documentation of PrEP clinical indication — notes addressing exposure risk and basis for the PrEP recommendation.
• Plan evidence of coverage — locate the PA requirement and any exception language for urgent or time-sensitive situations.

## Criteria-Mapping Structure

Copy each PA criterion from the Aetna policy verbatim. For each criterion, write one sentence identifying the specific chart note, date, and clinician whose documentation satisfies it. Submit this as a structured exhibit to your appeal cover letter. A criterion-by-criterion map that leaves nothing unanswered gives the reviewer the clearest path to approval.