Spravato denied as duplicate or overlapping therapy by Aetna?

Aetna's specific coverage criteria for spravato 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 May Deny Spravato as Duplicate Therapy

Aetna's duplicate-therapy denial means the plan's clinical reviewers concluded that another treatment you are already receiving serves the same therapeutic purpose as esketamine nasal spray (Spravato). For treatment-resistant depression (TRD) and major depressive disorder with acute suicidal ideation or behavior (MDSI), this most commonly arises when a patient is simultaneously prescribed another antidepressant or an IV ketamine infusion, and the reviewer argues functional overlap.

This denial is worth appealing because esketamine has a distinct FDA-approved mechanism, a unique REMS-restricted administration setting, and an approved indication for a specific clinical population. A well-documented appeal demonstrates that no currently prescribed agent covers the same indication in the same way.

## Federal Appeal Framework

• Internal appeal: Submit within the timeframe stated on your Explanation of Benefits (EOB) — typically 180 days. Aetna must respond within 30 days for prospective requests or 60 days for post-service claims.
• External review (ACA §2719 / ERISA §503): If the internal appeal is denied, you may request an Independent Review Organization (IRO) review. For most employer plans, the external-review window is generally up to four months from the internal denial notice. Self-funded ERISA plans carry the same full-and-fair review obligation.
• Expedited option: If waiting poses serious risk to health or life — including acute suicidal crisis — request expedited internal review (72-hour turnaround) and, if needed, expedited external review (72 hours).

## Documentation to Gather

1. Diagnosis confirmation: Treating psychiatrist's records confirming the precise DSM diagnosis and clinical severity. 2. Prior-treatment history: A chronological list of every antidepressant or augmentation agent tried, with start dates, stop dates, doses as titrated by the prescriber, and reason for discontinuation or inadequate response. 3. Current medication list: Demonstrate that any concurrent therapy addresses a different symptom domain or serves a different clinical purpose. 4. Prescriber medical-necessity letter: The letter should articulate why esketamine is not duplicative — specifically, the distinct FDA indication, the REMS-required in-office monitoring requirement, and the clinical differentiation from other agents on the regimen. 5. Applicable guideline support: Reference the relevant guideline organization (e.g., applicable American Psychiatric Association guidance) generically, without citing version-specific numbers.

## Criteria-Mapping Structure

Pull Aetna's published medical policy for esketamine and copy each criterion into a two-column table. In the right column, answer each requirement with the exact chart fact: specific diagnosis, documented treatment failures, current prescriptions, and why each concurrent agent does not duplicate esketamine's role. Submit this mapping as a cover sheet to your appeal packet so the reviewer can match your evidence directly to each criterion without interpretation.