Spravato denied as not medically necessary 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 for Medical Necessity

A medical-necessity denial for esketamine nasal spray (Spravato) from Aetna means the plan's reviewers concluded that the clinical record, as submitted, did not demonstrate that the drug is necessary, appropriate, and consistent with Aetna's coverage criteria for the patient's condition. For Spravato, this commonly occurs when the documentation of treatment-resistant depression (TRD) or major depressive disorder with acute suicidal ideation or behavior (MDSI) is incomplete — for example, when prior treatment failures are described vaguely, when severity is not quantified in the chart, or when the prescriber's rationale is absent.

This denial is among the most successfully overturned on appeal when the right documentation is assembled, because Spravato's FDA approval is well-established and Aetna's own policy identifies specific criteria that, if met and documented, require coverage.

## Federal Appeal Framework

• Internal appeal (ACA §2719 / ERISA §503): File within the deadline on your EOB. Aetna is required to render a decision within 30 days for prospective denials or 60 days for post-service claims.
• External review: If the internal appeal fails, request IRO review. The external-review window is generally up to four months from the final internal denial. An IRO applies an independent clinical standard, not Aetna's proprietary criteria.
• Expedited review: When delay poses serious risk to health or life (including acute suicidal risk), both internal (72-hour) and external (72-hour) expedited tracks are available.

## Documentation to Gather

1. Confirmed DSM diagnosis: Psychiatrist records specifying the diagnosis, current severity, and duration. 2. Treatment-failure log: A complete, dated list of prior antidepressant regimens — each drug, the adequate duration as documented in the chart, and the clinical outcome (partial response, no response, intolerance). Vague prior-treatment references are the most common reason medical-necessity appeals fail. 3. Severity documentation: Structured clinical assessments or chart notes quantifying current symptom burden. 4. Prescriber medical-necessity letter: A detailed letter from the treating psychiatrist explaining how the patient's documented history satisfies the eligibility criteria in the FDA-approved prescribing information and in Aetna's current medical policy. 5. Monitoring plan: Documentation that the required in-office administration and post-dose monitoring under the REMS program will be followed.

## Criteria-Mapping Structure

Download Aetna's published esketamine medical policy and the current FDA prescribing label. For every listed criterion, create a one-sentence response citing the specific page or date in the medical record that satisfies it. Submit this as a structured attachment. Reviewers who can match evidence directly to criteria approve appeals at higher rates than those who must extract the answer from narrative records.