Spravato denied as experimental or investigational 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 Experimental

An "experimental or investigational" denial from Aetna means a clinical reviewer determined that the evidence does not yet meet the plan's definition of accepted medical practice for your specific situation. For esketamine nasal spray (Spravato), this denial is most likely to appear when the request falls outside the two FDA-approved indications — treatment-resistant depression (TRD) and major depressive disorder with acute suicidal ideation or behavior (MDSI) — or when chart documentation does not clearly anchor the request to one of those indications.

This denial is strongly appealable for on-label use: Spravato carries full FDA approval for TRD and MDSI, it is subject to a REMS program confirming recognized clinical use, and major psychiatric professional organizations have addressed its use in guidance documents.

## Federal Appeal Framework

• Internal appeal (ACA §2719 / ERISA §503): File within the window shown on your EOB. Aetna must decide within 30 days (prospective) or 60 days (post-service).
• External review: After an adverse internal decision, an Independent Review Organization (IRO) can independently evaluate whether the denial meets accepted medical practice standards. The external-review window is typically up to four months from final internal denial.
• Expedited track: Patients facing imminent serious harm — including active suicidal crisis — may request expedited review at both the internal (72 hours) and external (72 hours) stages.

## Documentation to Gather

1. On-label confirmation: A prescriber letter explicitly stating which FDA-approved indication is being treated and citing the FDA approval. 2. Diagnosis records: Psychiatric evaluation confirming the DSM diagnosis, severity, and chronicity. 3. Failed-treatment history: Documented trials of prior adequate therapies, with dates and clinical outcomes, establishing that the patient meets the treatment-resistant or acute-severity criteria described in the FDA label. 4. REMS acknowledgment: Note that the drug is only dispensed and administered under a REMS program — this itself signals recognized clinical legitimacy. 5. Guideline organization reference: Cite the relevant professional body (e.g., applicable American Psychiatric Association resources) generically to show the treatment is within recognized medical practice.

## Criteria-Mapping Structure

Obtain Aetna's current medical policy on esketamine and the FDA-approved prescribing information. List every criterion the policy requires for non-experimental classification. For each criterion, provide the specific chart evidence that satisfies it. Where the policy requires prior treatment failures, name each agent tried, the duration, and the documented outcome. This side-by-side mapping prevents the reviewer from having to infer whether your case qualifies.