Aetna · Spravato · US health-plan appeal rights

Spravato denied as experimental or investigational by Aetna?

Q: How long do I have to appeal a Aetna Spravato denial?

Internal appeal window: Typically 180 days from the denial date. External review window: Typically 60–120 days after the final internal denial. The clock starts from the date on the denial letter.

An experimental denial requires the appeal to cite the FDA approval (if any), peer-reviewed phase III data, and the recognised specialty-society guideline that supports the treatment for your indication.

By Michael John Ryan, Founder & Privacy Officer, DenialHelp, LLC

Last reviewed 2026-05-09

Policy data current as of 2026-04-26

US health-plan appeal rights

Cite: Most US health plans have appeal rights under either the ACA, ERISA, or Medicare/Medicaid rules

Most US health plans are required by federal law to give you both an internal appeal (where the insurer reconsiders) and an external review (where an independent reviewer decides). The exact timelines and processes depend on what kind of plan you have — marketplace / employer group, self-funded, Medicare Advantage, or Medicaid MCO — but in every case there's a window after the denial during which you have the right to fight it.

Internal appeal window

Typically 180 days from the denial date

External review window

Typically 60–120 days after the final internal denial

What Aetna typically requires

TRD diagnosis: MDD with failure of >=2 adequate antidepressant trials at therapeutic dose >=6 wk in current episode (per FDA label). OR MDD with acute suicidal ideation/behavior (per Aug 2020 indication). Administered ONLY at REMS-certified site with >=2 hr post-dose monitoring (BP, sedation, dissociation). Reauth at induction completion (4 wk) with MADRS response; maintenance phase per SUSTAIN-1.

Source policy: Aetna CPB 0950: Esketamine (Spravato)

What works in the appeal

Spravato FDA-approved Mar 5, 2019 for TRD STANDALONE (with oral AD), Aug 3, 2020 for MDD with acute suicidal ideation. APA TRD 2022 + Voineskos JCP 2022 list ECT and esketamine as PARALLEL options — NOT step-therapy. TRANSFORM-2 Popova AJP 2019 — Spravato + AD vs AD-alone, primary endpoint met. SUSTAIN-1 Daly JAMA Psychiatry 2019 — relapse-prevention. ASPIRE-I/II — acute suicidal ideation. IV ketamine is OFF-LABEL; Spravato is FDA-approved with REMS — coverage required at REMS-certified site.

Next steps

Find the date on the denial letter — your appeal window starts there.
Read your plan's Summary of Benefits and Coverage (SBC) for the specific deadlines.
Request the insurer's claim file in writing — they must provide it.
Submit your appeal in writing with new clinical evidence and a physician statement.

Get the letter drafted

DenialHelp drafts your appeal in 5 minutes — $40 list price, $30 for your first letter (use code SEO25). We cite the federal regs and the specific clinical evidence your plan responds to. Your physician signs and sends.

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Related appeal guides

Other Aetna appeals

Other denial reasons for Aetna Spravato

denied as not medically necessary denied for failing step therapy denied as non-formulary denied for missing prior authorization denied as not FDA-approved for this use

This guide describes general US federal appeal rights based on Most US health plans have appeal rights under either the ACA, ERISA, or Medicare/Medicaid rules. Your specific plan documents (Summary of Benefits and Coverage, Evidence of Coverage) override anything here. DenialHelp is not your lawyer and not your physician — we draft appeal letters that your physician signs. Outcomes depend on your insurer's decision and factors outside our control. Reviewed by Michael John Ryan on 2026-05-09. Editorial standards: denialhelp.com/authors.