Aetna · Spravato · US health-plan appeal rights

Spravato denied for failing step therapy 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.

Step-therapy denials usually flip when the appeal documents that prior alternatives were tried and failed, or were contraindicated, or aren't safe for the patient.

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

Last reviewed 2026-05-10

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

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.

Source policy: Aetna Clinical Policy Bulletin: Esketamine (Spravato)

The Aetna angle on Spravato

## Why Aetna May Deny Spravato Under Step-Therapy

Aetna's step-therapy (also called "fail-first") denial for esketamine nasal spray (Spravato) means the plan requires documented failure of one or more lower-cost or more established antidepressant treatments before it will authorize Spravato. This is one of the most common denial types for Spravato, and it is also one of the most frequently overturned — not because the step-therapy requirement is improper, but because the prior treatment failures have already occurred and simply need to be documented thoroughly.

For patients with treatment-resistant depression (TRD), the prior-treatment failures are definitional to the diagnosis itself, which means the clinical record almost always contains the evidence needed to satisfy step-therapy requirements.

## Federal Appeal Framework

Internal appeal (ACA §2719 / ERISA §503): File within the deadline on your EOB. Aetna must respond within 30 days for prospective denials.
Step-therapy exception: Many states have enacted step-therapy exception laws, and the federal 21st Century Cures Act provides exception rights in certain plan types. The prescriber may request an exception if the required step agents are contraindicated, previously failed, or clinically inappropriate. Check whether your state's step-therapy exception law applies.
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.
Expedited track: Available (72 hours) when delay would seriously jeopardize health or life.

## Documentation to Gather

1. Complete step-therapy failure log: A detailed, chronological list of every prior antidepressant or augmentation agent the patient has tried. For each: the drug name, start and stop dates, maximum dose as documented in the chart, duration of adequate trial, and reason for discontinuation or inadequate response. Vague entries ("patient tried several antidepressants") are the primary reason step-therapy appeals fail. 2. Prescriber medical-necessity letter: A letter from the treating psychiatrist confirming that the patient meets the treatment-resistant criteria in the FDA-approved prescribing label and Aetna's medical policy, and explaining why further step-therapy trials would be clinically inappropriate or harmful. 3. Diagnosis confirmation: Chart documentation of the specific DSM diagnosis, severity, and duration. 4. Applicable guideline reference: Reference the relevant professional organization's guidance generically (e.g., applicable American Psychiatric Association guidance on treatment-resistant depression) to situate the prescriber's recommendation within recognized medical practice. 5. Step-therapy exception request (if applicable): If your state has a step-therapy exception law, file a simultaneous exception request with the appeal.

## Criteria-Mapping Structure

Download Aetna's current Spravato medical policy. List every required step-therapy agent. For each, provide the specific chart evidence (dates, drug name, documented outcome). Submit this as a structured table attached to your appeal letter. Reviewers who can match each required prior-treatment failure to a documented chart entry rarely uphold step-therapy denials.

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

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Related appeal guides

Other Aetna appeals

Other denial reasons for Aetna Spravato

denied as not medically necessary denied as non-formulary denied for missing prior authorization denied as experimental or investigational 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 2026-05-10. Editorial standards: denialhelp.com/authors.