TAVR Low Risk denied as duplicate or overlapping therapy by Aetna?

Aetna's specific coverage criteria for tavr low risk 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 Denies TAVR for Low Surgical Risk as Duplicate Therapy

Aetna may issue a duplicate-therapy denial when it determines that another cardiac procedure — typically surgical aortic valve replacement (SAVR) — is already available and considered equivalent in your clinical situation. For low-surgical-risk patients, Aetna's reviewers may argue that SAVR is the established standard and that authorizing TAVR alongside it constitutes redundant coverage for the same therapeutic goal.

This type of denial is appealing because the clinical picture of an individual patient frequently demonstrates that TAVR and SAVR are NOT interchangeable — anatomy, comorbidities, patient preference, and shared decision-making all factor into guideline-concordant care. The relevant professional societies (the American College of Cardiology and the Society of Thoracic Surgeons, among others) recognize both modalities as appropriate options across a range of surgical-risk profiles, and the treating structural heart team's recommendation carries significant weight.

## Federal Appeal Rights

You have the right to a full internal appeal under ERISA §503 (if employer-sponsored) or ACA §2719 (if ACA-compliant), followed by an independent external review if the internal appeal is denied. The external review window is generally available within approximately four months of the initial denial notice — confirm the exact deadline from the denial letter itself. An expedited review option exists when the standard timeline would seriously jeopardize your health.

## Appeal Process and Timeline

1. Request the denial rationale in writing. Obtain Aetna's full clinical criteria and the specific basis for the duplicate-therapy determination. 2. File a Level 1 internal appeal within the deadline shown on your denial letter (typically 180 days for ERISA plans). 3. If upheld, file a Level 2 appeal or proceed directly to external review, depending on your plan terms. 4. Request an expedited review if your clinical condition is urgent.

## Documentation to Gather

• Diagnosis confirmation: Echocardiographic and/or cardiac CT reports confirming severe aortic stenosis and anatomic suitability for TAVR.
• Surgical risk evaluation: Formal risk-score assessment from your cardiothoracic surgery team and your structural heart team's written recommendation.
• Why SAVR is not equivalent here: A detailed prescriber letter explaining why SAVR does not adequately address your specific anatomy, comorbidities, or clinical circumstances.
• Shared decision-making documentation: Notes reflecting the patient-provider discussion of both options and the clinical rationale for choosing TAVR.
• Applicable guidelines: Reference to current ACC/AHA valvular heart disease guidelines endorsing TAVR in low-surgical-risk patients — obtain the exact guideline version from your cardiologist.

## Criteria-Mapping Structure

Create a table with three columns: (1) Aetna's stated criterion for avoiding duplicate-therapy denial, (2) the corresponding clinical fact from your records, and (3) the source document. Work through every criterion Aetna cited line by line. This structured format makes it easy for the reviewer — and, if needed, an independent external reviewer — to confirm that your case does not meet the definition of duplicate therapy.