Spravato denied for missing prior authorization 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 Requires Prior Authorization for Spravato

Aetna requires prior authorization (PA) for esketamine nasal spray (Spravato) before it will cover the drug. This is a standard gatekeeping step — not an adverse coverage decision — but a PA denial or lapse in the PA process functions the same as a coverage denial in practice. PA denials for Spravato most commonly occur when the authorization request was incomplete, when required clinical documentation was missing, when the request was routed to the wrong benefit (pharmacy vs. medical), or when a subsequent course of treatment was started without renewing an expired prior authorization.

If a PA was submitted and denied, that denial is separately appealable under the processes below.

## Federal Appeal Framework

• Internal appeal (ACA §2719 / ERISA §503): A PA denial is a formal adverse benefit determination and triggers full internal-appeal rights. File within the deadline on the denial notice (typically shown on your EOB or PA denial letter). Aetna must decide within 30 days for prospective requests.
• Expedited PA review: If waiting for standard PA turnaround could seriously jeopardize health or life — including acute suicidal risk — request expedited review. Aetna must respond within 72 hours.
• External review: If the internal appeal of the PA denial is exhausted, IRO external review is available, generally within four months of the final internal adverse determination.

## Documentation to Gather

1. Completed PA request form: Obtain the current Aetna PA form for Spravato under the correct benefit (medical benefit is common given the REMS in-office administration requirement). Ensure every required field is completed. 2. Diagnosis and severity confirmation: Psychiatrist records confirming the DSM diagnosis, current clinical severity, and duration of illness. 3. Prior-treatment history: A complete, dated log of prior antidepressant trials — each drug, duration, and outcome — demonstrating that the patient meets the step-therapy or treatment-failure requirements in Aetna's PA criteria. 4. Prescriber medical-necessity letter: A letter from the treating psychiatrist specifically addressing each criterion in Aetna's published esketamine medical policy. 5. REMS site confirmation: Confirmation that the administering site is enrolled in the Spravato REMS program, as this is typically a required element of the PA.

## Criteria-Mapping Structure

Before submitting or resubmitting the PA, download Aetna's current esketamine medical policy and compare it against your documentation. For every criterion listed — diagnosis, treatment failures, prescriber specialty, administration setting — confirm you have a corresponding document. A PA denial is most efficiently resolved by a clean, complete resubmission that pre-answers every criterion, rather than waiting for a denial and then appealing.