TAVR Low Risk denied for missing prior authorization 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 Requires Prior Authorization for TAVR in Low Surgical Risk

Prior authorization (PA) denial for TAVR means the procedure was performed or requested without first obtaining Aetna's advance approval — or that the PA request was submitted but denied because the required clinical documentation was incomplete, did not match Aetna's coverage criteria, or the request was not processed in time. TAVR is a high-cost, complex structural heart procedure, and Aetna uniformly requires PA for it. A PA denial does not necessarily mean Aetna believes TAVR is inappropriate; it may simply mean the administrative process was not completed correctly.

If the PA was denied on clinical grounds, this functions as a medical-necessity denial and the full appeal process applies. If it was denied on procedural grounds (retroactive or missing PA), the appeal focuses on demonstrating either that the urgency of the case prevented advance authorization or that the treating team believed PA had been obtained.

## Federal Appeal Rights

You have the right to a full internal appeal under ERISA §503 or ACA §2719, followed by independent external review if the internal appeal fails. The external review window is generally within four months of the final denial — confirm the exact deadline from your denial letter. For urgent ongoing or upcoming procedures, request expedited review immediately.

## Appeal Process and Timeline

1. Determine the exact reason for PA denial: Was it a missing submission, a documentation gap, or a clinical coverage determination? The remediation path differs. 2. If administrative: Submit the correct PA request with a complete clinical package immediately. Request retroactive authorization if the procedure has already occurred. 3. If clinical: File a formal Level 1 internal appeal with targeted documentation addressing each unmet criterion Aetna cited. 4. Escalate to external review if the internal appeal is denied.

## Documentation to Gather

• Prior authorization request records: Dates of submission, reference numbers, and any communication from Aetna about the PA request.
• Clinical urgency documentation: If the procedure was performed without PA due to clinical urgency, physician notes documenting why delay would have been harmful.
• Complete clinical package for coverage criteria: Echocardiogram and cardiac CT confirming severe aortic stenosis and TAVR suitability; formal surgical risk assessment; structural heart team recommendation.
• Prescriber medical-necessity letter: A detailed letter from the interventional cardiologist documenting why TAVR meets Aetna's stated medical-necessity criteria for low-surgical-risk patients.
• Aetna's PA criteria: Request a copy of the exact criteria Aetna uses to evaluate TAVR PA requests so your appeal can address each requirement explicitly.

## Criteria-Mapping Structure

For a PA appeal, map Aetna's PA criteria — obtained from the denial letter or Aetna's published clinical policy — against the clinical facts in your records. Present each criterion in a table with the corresponding documentation. If the denial was procedural rather than clinical, include a chronological timeline of events showing that the clinical team acted appropriately given the circumstances. This structured presentation gives the reviewer a clear path to approval.