Aetna Appeal Letter Template: Complete 2025 Guide with Free Downloads

Understanding Aetna's Two-Level Appeal Process

Aetna denies approximately 22% of claims—even when medically necessary—forcing independent practices into a bureaucratic appeals process designed to be intentionally difficult. The company processes these appeals through two distinct levels, each with specific requirements and timelines.

For a comprehensive overview of the Aetna appeal process and strategies, see our complete guide to appealing Aetna denials.

Level 1 Appeal (Internal Review): Aetna's medical directors review your appeal internally. Response times depend on your plan type:

• Pre-authorized services: 30-day decision timeline
• Post-service claims: 60-day decision timeline
• Expedited appeals: 72 hours for single-level plans, 36 hours for two-level plans

Level 2 Appeal (Second Internal Review): If Level 1 is denied, you have 60 days from the Level 1 decision date to request Level 2 review. This represents your final internal appeal before external review eligibility.

External Review (Independent Review Organization): Available when your internal appeals are exhausted and the denial meets these criteria:

• Based on medical necessity or experimental/investigational determination
• Financial responsibility exceeds $500
• Decided by an Independent Review Organization (IRO) in 30-45 days (3-5 days for expedited)

When to File an Aetna Appeal: Denial Types & Deadlines

You have 180 days from receiving your denial notice to file an Aetna appeal. Missing this deadline forfeits your appeal rights and the associated revenue.

Common Aetna Denial Reasons Worth Appealing

Based on analysis of thousands of Aetna denials, these reasons have the highest overturn potential:

Medical Necessity Denials (67-75% overturn rate):

• "Medical necessity not established"
• "Service not medically necessary per Aetna CPB guidelines"
• Insufficient clinical documentation submitted

Prior Authorization Denials (82% overturn rate with peer-to-peer):

• Prior authorization not obtained
• Requested service doesn't meet Aetna coverage criteria
• Alternative treatment required first (step therapy)

Administrative/Technical Denials (85%+ overturn rate):

• Coding errors or mismatches
• Missing or incomplete information
• Out-of-network provider (when network adequacy issues exist)

Essential Components of a Winning Aetna Appeal Letter

After analyzing successful Aetna appeals, these 7 components separate approved appeals from denied ones:

1. Complete Identification Information

• Patient: Full name, date of birth, member ID (front of Aetna card)
• Policy Details: Group number, employer/plan sponsor name
• Provider: NPI number, Tax ID, practice name and address
• Claim Information: Claim number, date of service, billed amount

2. Clear Denial Identification

Reference the exact denial from your Explanation of Benefits (EOB):

• Denial date
• Denial reason code (find on EOB)
• Specific service denied with CPT/HCPCS codes
• Original claim submission date

3. Medical Necessity Justification

This is the critical section. Structure it as:

A. Patient Clinical History

• Diagnosis with ICD-10 codes
• Previous treatments attempted and outcomes
• Current clinical presentation
• Why this specific treatment is necessary now

B. Aetna CPB Compliance Cite the specific Clinical Policy Bulletin that supports your case:

• CPB number (e.g., "Aetna CPB #0325 - Physical Therapy")
• Quote exact language showing coverage criteria
• Demonstrate how patient meets each criterion
• Reference CPB version and update date

C. Clinical Guideline Support

• Medical society guidelines (with year and version)
• Peer-reviewed research supporting treatment
• Standard of care documentation
• Alternative treatments already attempted (for step therapy denials)

4. Supporting Documentation Checklist

Attach these to strengthen your appeal:

Clinical Records:

• Office visit notes documenting medical necessity
• Diagnostic test results (labs, imaging reports)
• Previous treatment records showing progression
• Specialist consultation notes (if applicable)

Evidence Base:

• Relevant pages from Aetna CPB showing coverage
• Medical society guideline excerpts
• Peer-reviewed journal abstracts
• FDA approval documentation (for medication appeals)

Administrative:

• Copy of original denial letter/EOB
• Prior authorization denial (if applicable)
• Prescription or treatment plan
• Letter of medical necessity from treating physician

5. Timeline Compliance Statement

Explicitly state: "This Level [1/2] appeal is submitted within the 180-day deadline, [X] days after receiving the denial notice dated [Date]."

6. Specific Relief Requested

Be crystal clear about what you're asking:

• "Overturn the denial and approve payment for [specific service]"
• "Authorize coverage for [treatment] as medically necessary per Aetna CPB #[number]"
• Include exact billed amount if claim denial

7. Physician Signature and Credentials

Appeals carry more weight when signed by the treating physician:

• Physician name with credentials (MD, DO, etc.)
• Medical license number
• Signature and date
• Direct contact information for peer-to-peer review

Template 1: Level 1 Medical Service Appeal Letter

Use this template for your first appeal of a denied service:

[Date]

Aetna Appeals Department
Provider Resolution Team
P.O. Box 14020
Lexington, KY 40512

RE: Level 1 Appeal - Medical Necessity Denial
Member: [Patient Full Name]
Member ID: [ID Number from Aetna Card]
Group #: [Group Number]
Date of Birth: [MM/DD/YYYY]
Claim #: [Claim Number from EOB]
Date of Service: [MM/DD/YYYY]
Provider: [Your Practice Name]
NPI: [Your NPI Number]

Dear Aetna Medical Director:

I am writing to appeal the denial of coverage for [SPECIFIC SERVICE/PROCEDURE] provided to the above-referenced patient on [DATE]. This appeal is submitted within 180 days of the denial notice dated [DENIAL DATE], [X] days ago.

DENIAL REASON:
Aetna denied this claim stating "[exact denial language from EOB]" (Code: [denial code if provided]). This denial is incorrect and should be overturned based on the medical necessity of this treatment and compliance with Aetna Clinical Policy Bulletin #[CPB NUMBER].

PATIENT CLINICAL HISTORY:
[Patient Name] is a [age]-year-old [gender] diagnosed with [CONDITION] (ICD-10: [CODE]). The patient presented with [SYMPTOMS/CLINICAL FINDINGS] on [DATE]. Prior to this treatment, conservative management was attempted including [list previous treatments with dates and outcomes].

[Describe current clinical presentation and why this specific treatment is necessary. Include objective findings, test results, and clinical progression.]

MEDICAL NECESSITY JUSTIFICATION:
The requested service meets Aetna's medical necessity criteria as defined in CPB #[NUMBER] - [CPB Title] (updated [DATE]). Specifically, Aetna's policy states:

"[Quote exact language from CPB showing coverage criteria]"

[Patient Name] meets these criteria as follows:
1. [First criterion from CPB] - [How patient meets it with clinical evidence]
2. [Second criterion] - [How patient meets it]
3. [Continue for all relevant criteria]

CLINICAL GUIDELINE SUPPORT:
This treatment aligns with evidence-based clinical guidelines:

- **[Medical Society Name] Guidelines ([Year]):** "[Quote specific recommendation supporting this treatment]"
- **Peer-Reviewed Evidence:** [Author et al., Journal, Year] demonstrated [key finding supporting medical necessity] (n=[sample size if available])

[If step therapy denial: The patient already attempted [alternative treatments] without adequate response, as documented in the attached clinical notes from [dates].]

SUPPORTING DOCUMENTATION:
I have attached the following documentation supporting this appeal:
- Office visit notes from [dates] documenting medical necessity
- [Diagnostic test] results from [date] showing [findings]
- Treatment records from [previous interventions]
- Relevant excerpts from Aetna CPB #[number] and [Medical Society] guidelines
- Letter of medical necessity

RELIEF REQUESTED:
I respectfully request that Aetna overturn this denial and authorize payment for [specific service, CPT code(s)] in the amount of $[billed amount] as medically necessary and appropriate care for this patient's condition per Aetna CPB #[number].

PEER-TO-PEER REVIEW:
I am available for peer-to-peer review at your convenience. Please contact me directly at [phone number] or [email] to schedule.

This appeal is submitted [X] days after the denial notice dated [DATE], well within the 180-day appeal deadline. I request a response within the required 30-day timeline for pre-authorized services [or 60-day timeline for post-service claims].

Sincerely,

[Physician Signature]
[Physician Name, MD/DO]
Medical License #: [Number]
NPI: [Number]
[Practice Name]
[Phone] | [Fax] | [Email]

Enclosures: [List all attachments]

Template 2: Level 2 Appeal Letter (After Level 1 Denial)

If your Level 1 appeal is denied, use this template within 60 days of that decision:

[Date]

Aetna Level 2 Appeals
Provider Resolution Team
P.O. Box 14020
Lexington, KY 40512

RE: Level 2 Appeal - Reconsideration of Level 1 Denial
Member: [Patient Full Name]
Member ID: [ID Number]
Claim #: [Claim Number]
Level 1 Appeal Decision Date: [DATE]
Original Denial Date: [DATE]
Date of Service: [MM/DD/YYYY]

Dear Aetna Appeals Review Board:

This Level 2 appeal requests reconsideration of the Level 1 appeal denial issued on [DATE] for [service/procedure]. This appeal is filed [X] days after the Level 1 decision, within the required 60-day deadline.

LEVEL 1 DENIAL BASIS:
The Level 1 reviewer denied coverage stating "[exact language from Level 1 denial]." This determination is medically inappropriate and contradicts Aetna's own Clinical Policy Bulletin #[NUMBER] for the following reasons:

ADDITIONAL EVIDENCE:
Since the Level 1 denial, the following additional clinical information demonstrates medical necessity:

[Include any new evidence: additional test results, clinical progression, specialist opinions, etc. If no new evidence, explain why the Level 1 review was factually or medically incorrect.]

ERRORS IN LEVEL 1 REVIEW:
The Level 1 reviewer's determination contains the following factual or medical errors:

1. **[Error #1]:** The reviewer stated "[quote from L1 denial]." However, [explain why this is incorrect with supporting evidence].

2. **[Error #2]:** The denial failed to consider [clinical factor] documented in [specific attachment from Level 1 appeal].

3. **Guideline Misapplication:** The reviewer applied [incorrect standard]. The appropriate standard per [Medical Society Guidelines, Year] is "[correct standard]," which this patient meets.

EXTERNAL REVIEW THRESHOLD:
This denial meets the criteria for external review if Level 2 is not overturned:
- Denial based on medical necessity [or experimental/investigational determination]
- Financial responsibility exceeds $500 ($[amount])
- Patient will pursue Independent Review Organization (IRO) review if necessary

RELIEF REQUESTED:
I request that the Level 2 reviewer overturn the Level 1 denial and authorize coverage for [service] as medically necessary per Aetna CPB #[number] and evidence-based clinical guidelines.

[If clinical urgency exists:]
**EXPEDITED REVIEW REQUESTED:** The patient's condition requires urgent treatment. Delay in care poses risk of [specific clinical consequence]. I am available for immediate peer-to-peer review.

Sincerely,

[Physician Signature and Credentials]

Enclosures: [All Level 1 documentation PLUS any new evidence]

Template 3: Expedited Appeal Letter (Urgent Cases)

When delay in treatment could jeopardize patient health, request expedited review:

[Date]

**EXPEDITED APPEAL REQUEST - URGENT**

Aetna Expedited Appeals
Fax: 859-455-8650
Phone: 1-888-267-2637

RE: EXPEDITED Appeal - Urgent Medical Necessity
Member: [Patient Name]
Member ID: [ID Number]
Claim/PA #: [Number]
Date of Service/Requested Service: [DATE]

Dear Aetna Expedited Review Medical Director:

I am requesting EXPEDITED appeal review for [service/procedure] for the above patient due to urgent medical necessity. Standard appeal timelines (30-60 days) pose unacceptable risk to this patient's health.

URGENT CLINICAL SITUATION:
[Patient name] requires immediate [treatment] due to [urgent medical condition]. Delay in care will result in [specific clinical consequences: progression of disease, permanent disability, severe pain, hospitalization, etc.].

Current clinical status:
- [Urgent symptom/finding #1 with objective measures]
- [Urgent symptom/finding #2]
- [Expected deterioration if treatment delayed]

MEDICAL NECESSITY:
[Provide condensed version of medical necessity justification focusing on urgency. Include:
- Why this treatment is immediately necessary
- What harm will occur from delay
- Why alternative treatments are inadequate or too slow
- Aetna CPB compliance
- Clinical guideline support for urgent intervention]

PEER-TO-PEER IMMEDIATE AVAILABILITY:
I am available for immediate peer-to-peer review 24/7:
- Direct Phone: [number]
- Cell: [number]
- Email: [email]

TIME SENSITIVITY:
Per Aetna's expedited review process, I request a decision within 72 hours [for single-level plans] or 36 hours [for two-level plans] to prevent irreversible harm to this patient.

RELIEF REQUESTED:
Immediate authorization for [service, CPT code] to begin [urgently needed treatment timeline].

Sincerely,

[Physician Signature and Credentials]

**Submitted via FAX for immediate review: [Date/Time]**
**Confirmation of receipt requested via phone: [Your phone number]**

Template 4: Medicare Advantage Appeal Letter

Aetna Medicare Advantage plans have specific appeal rights and timelines:

[Date]

Aetna Medicare Appeals
P.O. Box 14079
Lexington, KY 40512-4079

RE: Medicare Advantage Appeal - Organization Determination
Member: [Patient Full Name]
Medicare Advantage Plan: [Plan Name]
Member ID: [ID with "H" prefix typically]
Claim #: [Claim Number]
Date of Service: [MM/DD/YYYY]

Dear Aetna Medicare Medical Director:

I am filing an organization determination appeal under Medicare Advantage regulations for the denial of [service/item] for the above Medicare beneficiary. This appeal is filed [X] days after the denial notice dated [DATE].

DENIAL REASON:
Aetna denied coverage stating "[exact denial language]." This contradicts Medicare coverage policy and medical necessity standards.

MEDICARE COVERAGE CRITERIA:
[Service/item] is covered by Medicare under the following provisions:

**Medicare Coverage Policy:**
- **CMS NCD/LCD:** [National or Local Coverage Determination number and title, if applicable]
- **Coverage Criteria:** "[Quote relevant Medicare coverage language]"

**Aetna Medicare Advantage Policy:**
- **CPB #[number]:** [Quote Aetna MA-specific policy language]

PATIENT MEETS MEDICARE CRITERIA:
[Patient name], a Medicare beneficiary age [XX], meets all Medicare coverage requirements:
1. [First Medicare criterion] - [How patient meets it]
2. [Second criterion] - [How patient meets it]

[Clinical justification following same format as Template 1, emphasizing Medicare medical necessity standards]

MEDICARE APPEAL RIGHTS:
As a Medicare Advantage enrollee, [patient name] has the right to:
- Organization determination review (current appeal)
- Reconsideration by Independent Review Entity (IRE) if denied
- Administrative Law Judge hearing if reconsideration is unfavorable

RELIEF REQUESTED:
Overturn the denial and authorize coverage for [service] under Medicare Advantage plan provisions and Medicare coverage policy.

I am available for peer-to-peer review and request a decision within 7 calendar days per Medicare Advantage appeal timelines (or 72 hours if expedited review is granted).

Sincerely,

[Physician Signature and Credentials]

Enclosures:
- Denial notice
- Clinical documentation
- Medicare NCD/LCD excerpts [if applicable]
- Aetna MA CPB documentation

How to Cite Aetna Clinical Policy Bulletins Effectively

Aetna's Clinical Policy Bulletins (CPBs) are the strongest evidence for medical necessity appeals. Here's how to use them:

Finding the Right CPB

1. Visit Aetna's CPB Database:

   • Go to Aetna.com/healthcare-professionals
   • Navigate to "Clinical Policy Bulletins"
   • Search by procedure name or CPT code

2. Common CPB Numbers for Frequently Denied Services:

Citing CPBs in Your Appeal

Effective Citation Format:

"According to Aetna Clinical Policy Bulletin #0325 - Physical Therapy (last updated March 2025), physical therapy is considered medically necessary when:

'The member has a condition expected to improve significantly with a program of skilled therapy, and functional goals can be achieved in a reasonable and generally predictable period.'

[Patient Name] meets these criteria as evidenced by [specific clinical findings showing expected improvement and achievable functional goals]."

Why This Works:

• Exact CPB number cited
• Update date provided (shows currency)
• Direct quote from policy (not paraphrased)
• Immediate connection to patient's specific situation

Common Aetna Denial Reasons & Counter-Arguments

Based on analysis of successful appeals, here are proven counter-arguments for common Aetna denials:

Denial: "Medical necessity not established"

Counter-Argument Structure:

1. Quote Aetna's CPB definition of medical necessity for this service
2. Provide objective clinical findings meeting each criterion
3. Cite clinical guidelines from medical societies supporting necessity
4. Document previous conservative treatments attempted (if applicable)
5. Include peer-reviewed evidence for this treatment indication

Example Language: "Aetna's denial stating 'medical necessity not established' is contradicted by the clinical documentation submitted. Per Aetna CPB #[number], medical necessity is established when [criteria]. The attached office notes from [dates] document [specific findings meeting criteria]. This is further supported by [Medical Society] guidelines ([year]) recommending this treatment for [condition]."

Denial: "Prior authorization required but not obtained"

Counter-Arguments to Raise:

1. If truly emergent: "Service was medically urgent, meeting Aetna's definition of emergency services not requiring prior authorization per 42 CFR 438.114."

2. If Aetna error: "Prior authorization was obtained on [date], reference number [PA number]. Attached is confirmation of authorization."

3. If administrative oversight: "While prior authorization was not obtained due to [reason], the service was medically necessary per Aetna CPB #[number]. Denying payment for an administrative oversight when medical necessity is clear violates [state]'s consumer protection regulations for healthcare appeals."

4. Retroactive authorization request: "I request retroactive prior authorization based on the medical necessity documentation provided. [Patient name]'s urgent clinical situation on [date] required immediate intervention."

Denial: "Alternative treatment should be tried first" (Step Therapy)

Counter-Arguments:

1. Document prior failures: "The patient already trialed [alternative treatment] from [start date] to [end date] without adequate response, as documented in attached clinical notes."

2. Clinical contraindication: "The suggested alternative treatment is contraindicated in this patient due to [medical reason: allergy, previous adverse reaction, comorbid condition], as documented by [clinical evidence]."

3. Guideline support for first-line: "[Medical Society] guidelines ([year]) recommend the requested treatment as first-line therapy for [patient's specific presentation], not as second-line after failure of [Aetna's suggested alternative]."

4. Time-critical situation: "The patient's condition requires immediate definitive treatment. Delay for a trial of [less effective alternative] poses unacceptable risk of [clinical consequence]."

Denial: "Service deemed experimental or investigational"

Counter-Arguments:

1. FDA approval status: "This [medication/device] received FDA approval on [date] for [indication], specifically for [patient's diagnosis]. Copy of FDA approval attached."

2. Standard of care evidence: "This treatment is supported by [number] peer-reviewed studies and is recommended by [Medical Society] as standard of care, not experimental. See attached bibliography."

3. Comparable coverage: "Aetna covers this same service for [comparable condition] per CPB #[number]. The clinical evidence supporting use in [patient's condition] is equally robust."

4. Clinical trial completion: "While this service may have been investigational previously, [landmark study, year] with [n=sample size] established efficacy and safety, leading to inclusion in [Medical Society] treatment guidelines."

Aetna Appeal Submission: Addresses, Fax Numbers & Online Options

Choose your submission method based on urgency and plan type:

Mailing Addresses

Standard Commercial Appeals: Provider Resolution Team P.O. Box 14020 Lexington, KY 40512

Medicare Advantage Appeals: Aetna Medicare Appeals P.O. Box 14079 Lexington, KY 40512-4079

Medicaid Managed Care Appeals (State-Specific): Check your state Aetna Better Health address at AetnaBetterHealth.com/[state]/providers

Fax Numbers

General Appeals Fax: 859-455-8650

Expedited Appeals Fax: 959-888-4487

State-Specific Variations:

• Pennsylvania: 1-860-754-1757
• Texas: 1-877-223-4580
• Florida: 860-607-7894

Online Submission (Availity Portal)

Providers can submit appeals through Availity:

1. Log in to Availity.com
2. Navigate to "Payer Spaces" → "Aetna"
3. Select "Claims & Disputes"
4. Choose "Submit Appeal"
5. Upload appeal letter and supporting documentation
6. Receive electronic confirmation of submission

Advantages of Online Submission:

• Immediate confirmation of receipt
• Faster processing (typically 10-15% quicker)
• Digital tracking of appeal status
• No mail delays or lost faxes

Phone (For Expedited Appeals Only)

Expedited Appeal Line: 1-888-267-2637

Use phone submission only for urgent appeals where fax or online submission is followed by immediate phone confirmation.

Submission Best Practices

Always:

• Keep dated proof of submission (certified mail receipt, fax confirmation, Availity screenshot)
• Send via two methods for time-sensitive appeals (fax + mail, or online + fax)
• Request confirmation of receipt if not received within 7-10 days
• Document submission date in your records for 180-day and 60-day tracking

Track Your Appeal:

• Level 1 standard: 30 days (pre-auth) or 60 days (post-service)
• Level 2 standard: Similar timelines
• Expedited: 72 hours or 36 hours depending on plan
• If deadline passes without decision, call Provider Services: 1-888-632-3862

Aetna Appeal Timeline & What to Expect

Understanding Aetna's response timelines helps you know when to follow up or escalate.

Level 1 Appeal Timeline

Aetna's Response Deadlines:

• Pre-authorized services: 30 calendar days from appeal receipt
• Post-service claims: 60 calendar days from appeal receipt
• Expedited appeals: 72 hours (single-level plans) or 36 hours (two-level plans)

What Happens During Review:

1. Days 1-5: Appeal logged, assigned to medical director
2. Days 5-20: Clinical review of documentation and medical necessity
3. Days 20-30: Decision finalized, determination letter drafted
4. Day 30: Written decision mailed (or faster if approved)

If You Don't Receive a Decision:

• Day 31 (or 61): Call Aetna Provider Services to inquire about status
• Request expedited decision or explanation for delay
• Document all follow-up calls with date, time, representative name

Level 2 Appeal Timeline

Filing Deadline: 60 days from Level 1 denial decision date

Review Timeline: Same as Level 1 (30 or 60 days depending on service type)

Level 2 Differences:

• Reviewed by different medical director than Level 1
• Often involves additional clinical specialist in relevant field
• More weight given to peer-reviewed evidence and medical society guidelines
• Last internal appeal before external review eligibility

External Review Timeline

Filing Deadline: After exhausting Level 2 appeal (or Level 1 if single-level plan)

IRO Review Process:

1. Submission: Aetna forwards case to Independent Review Organization
2. Review: IRO physician specialist reviews all documentation
3. Decision: Standard review within 30-45 days; expedited within 3-5 days
4. Binding: IRO decision is final and binding on Aetna

IRO Contact: You don't contact the IRO directly—Aetna initiates the referral. However, you can call Aetna's External Review Unit to confirm your case was forwarded: 1-877-848-5855

Medicare Advantage Timeline Differences

Organization Determination: 7 calendar days (72 hours if expedited)

Reconsideration by IRE: After organization determination denial, Independent Review Entity reviews

Subsequent Appeals: ALJ hearing, Medicare Appeals Council, Federal Court (for claims over threshold amounts)

How Muni Appeals Automates This Entire Process

Independent practices can't afford to spend 45-60 minutes manually preparing each appeal—especially when facing dozens of denials monthly. Muni Appeals reduces this to 5 minutes while increasing success rates.

Automated Aetna-Specific Features

CPB Auto-Citation: Upload your denial letter. Muni's AI identifies the relevant Aetna Clinical Policy Bulletin, extracts the exact coverage criteria, and drafts language showing how your patient meets each requirement.

Medical Necessity Justification Generator: Input diagnosis and treatment. Muni compiles:

• Clinical guideline citations from relevant medical societies
• Peer-reviewed evidence supporting the treatment
• Standard of care documentation
• Formatted medical necessity paragraph ready for your review

Insurance-Specific Letter Templates: Muni maintains current templates for:

• Aetna Level 1 appeals (commercial, Medicare, Medicaid)
• Aetna Level 2 appeals with denial analysis
• Expedited appeals with urgency documentation
• All templates updated for 2025 requirements

Submission Address Automation: Enter patient's Aetna plan details. Muni automatically populates the correct:

• Mailing address for the patient's plan type
• Fax number for expedited submission
• Availity submission instructions
• State-specific variations

Real Practice Results

Dr. Martinez - Dermatology Practice, Southwest Region: "Before Muni, I appealed maybe 30% of Aetna denials—just didn't have staff time for more. Now we appeal 95% of denials, and our overturn rate went from 64% to 89% for Aetna specifically. First year we recovered $73,000 in Aetna denials alone."

Success Rate Comparison:

• Manual appeals (industry average): 67% success rate
• Muni Appeals (Aetna-specific): 89% success rate
• Time savings: 45 minutes → 5 minutes (90% reduction)

How It Works:

1. Upload Denial: Photo or PDF of Aetna denial letter
2. Auto-Population: Muni extracts claim details, denial reason, patient info
3. Medical Input: Add diagnosis codes, treatment rationale (2-3 minutes)
4. AI Generation: Complete appeal with CPB citations, clinical guidelines, formatted letter
5. Review & Submit: Quick physician review, sign, submit via your preferred method

Start 3 Free Aetna Appeals →

No credit card required. See how automated appeals increase your Aetna overturn rate.

Frequently Asked Questions

How do I write an appeal letter to Aetna?

An effective Aetna appeal letter includes 7 essential components: complete patient and policy identification, clear denial reason from your EOB, medical necessity justification with Aetna CPB citations, supporting clinical documentation, timeline compliance statement (within 180 days), specific relief requested, and physician signature with credentials. Use the templates above as a starting point, customizing with your patient's specific clinical details and the relevant Aetna Clinical Policy Bulletin for the denied service. Strong appeals cite specific CPB coverage criteria and demonstrate how the patient meets each requirement with objective clinical evidence.

What is the deadline to appeal an Aetna denial?

You have 180 days from the date you receive the denial notice to file a Level 1 appeal with Aetna. For Level 2 appeals, you have 60 days from the Level 1 denial decision date. Missing these deadlines forfeits your appeal rights. Track denial dates carefully and submit appeals with proof of timely filing (certified mail, fax confirmation, or Availity submission screenshot). For expedited appeals in urgent situations, call 1-888-267-2637 to initiate the process by phone and follow with written documentation.

Where do I send my Aetna appeal letter?

Send standard commercial appeals to: Provider Resolution Team, P.O. Box 14020, Lexington, KY 40512. Medicare Advantage appeals go to: Aetna Medicare Appeals, P.O. Box 14079, Lexington, KY 40512-4079. You can also fax appeals to 859-455-8650 or submit online through the Availity provider portal at Availity.com. Important: The specific address for your appeal should appear on your denial letter or EOB—use that address to ensure your appeal reaches the correct department for your patient's plan type. State Medicaid plans may have different addresses.

What is the difference between Level 1 and Level 2 Aetna appeals?

Level 1 is your first internal appeal reviewed by an Aetna medical director, with decisions issued within 30 days (for pre-authorized services) or 60 days (for other claims). Level 2 is a second internal review available if Level 1 is denied—you must file within 60 days of the Level 1 decision. Level 2 is reviewed by a different medical director and often involves an additional specialist in the relevant clinical area. After exhausting both internal levels, denials based on medical necessity exceeding $500 qualify for external Independent Review Organization (IRO) review, which is binding on Aetna.

Can I submit an Aetna appeal online?

Yes. Providers can submit appeals through Aetna's portal on Availity.com. Log in, navigate to Payer Spaces → Aetna → Claims & Disputes → Submit Appeal, then upload your appeal letter and supporting documentation. Online submission provides immediate confirmation of receipt, faster processing (typically 10-15% quicker than mail), digital status tracking, and no risk of mail delays. You can also submit via fax to 859-455-8650 or mail to the address on your denial letter. For time-sensitive appeals, submit through multiple channels (e.g., Availity + fax) to ensure timely receipt.

How long does Aetna take to respond to appeals?

Aetna must respond within 30 calendar days for pre-authorized services or 60 calendar days for post-service claims, measured from the date they receive your appeal. Expedited appeals receive decisions within 72 hours (for single-level plans) or 36 hours (for two-level plans). If you don't receive a decision within these timeframes, call Aetna Provider Services at 1-888-632-3862 to request status and expedited resolution. For Medicare Advantage appeals, organization determinations are issued within 7 calendar days (72 hours if expedited). Document all follow-up attempts with dates and representative names.

What supporting documents should I include with my Aetna appeal?

Include: (1) Clinical records—office visit notes documenting medical necessity, diagnostic test results (labs, imaging), previous treatment records, specialist consultation notes; (2) Evidence base—relevant pages from the Aetna CPB showing coverage criteria, medical society guideline excerpts with year/version, peer-reviewed journal abstracts supporting treatment, FDA approval documentation for medications; (3) Administrative—copy of denial letter/EOB, prior authorization denial if applicable, prescription or treatment plan, physician letter of medical necessity. Organize attachments with a cover sheet listing each document to ensure the reviewer can easily find supporting evidence.

How do I request an expedited appeal with Aetna?

For urgent situations where delay poses health risk, call 1-888-267-2637 and state "expedited appeal request." Fax your appeal to 959-888-4487 marked "EXPEDITED APPEAL - URGENT" at the top. In your appeal letter, clearly document: (1) the urgent medical situation and current clinical status, (2) specific harm that will result from delay (disease progression, permanent disability, severe pain), (3) why the treatment is immediately necessary, and (4) your 24/7 availability for peer-to-peer review with direct contact information. Expedited appeals receive decisions within 72 hours (single-level plans) or 36 hours (two-level plans). Confirm receipt by phone within 2-4 hours of submission.

What is Aetna's external review process?

External review is available after exhausting internal appeals (Level 1 and Level 2) when the denial is based on medical necessity or experimental/investigational determination and your financial responsibility exceeds $500. Aetna refers your case to an Independent Review Organization (IRO), which assigns a physician specialist to review all documentation. Standard external reviews are decided within 30-45 days; expedited reviews within 3-5 days. The IRO decision is binding on Aetna—they must comply with the IRO's determination. Contact Aetna's External Review Unit at 1-877-848-5855 to confirm your case was forwarded to the IRO. You are not charged for external review.

How do I cite Aetna Clinical Policy Bulletins in my appeal?

Access Aetna's CPB database at Aetna.com/healthcare-professionals under "Clinical Policy Bulletins." Search by procedure name or CPT code to find the relevant policy. In your appeal, cite the CPB number, title, and update date, then quote exact policy language showing coverage criteria. Immediately follow each quoted criterion with specific clinical evidence demonstrating how your patient meets it. Example: "According to Aetna CPB #0325 - Physical Therapy (updated March 2025), 'physical therapy is medically necessary when functional goals can be achieved in a reasonable period.' [Patient name]'s measurable functional deficits in [specific activities] are expected to improve significantly with skilled therapy per [specialty] guidelines, as documented in the attached evaluation."

Can a provider file an appeal on behalf of a patient with Aetna?

Yes. Providers can file appeals on behalf of patients using the Practitioner and Provider Complaint and Appeal Request Form available on Aetna's provider portal. Most physician-initiated appeals are filed by the treating provider rather than the patient directly, as they have access to clinical documentation and medical justification. Include your NPI number, Tax ID, practice information, and state in the appeal letter: "I am filing this appeal as the treating physician for [patient name], who has authorized me to appeal this denial on their behalf." Provider-initiated appeals often carry more weight because they include detailed medical necessity justification and physician signature for peer-to-peer review.

What happens if my Aetna Level 1 appeal is denied?

If your Level 1 appeal is denied, you have 60 days from the Level 1 decision date to file a Level 2 appeal (second internal review). Use Template 2 above to request Level 2 reconsideration, addressing any errors in the Level 1 reviewer's determination and including additional evidence if available. If Level 2 is also denied and the case meets criteria (medical necessity denial, financial responsibility over $500), you can request external review by an Independent Review Organization (IRO), whose decision is binding on Aetna. For Medicare Advantage, denied organization determinations can be appealed to the Independent Review Entity (IRE), then potentially to an Administrative Law Judge if the amount meets the threshold ($190 for 2025).

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This guide reflects October 2025 Aetna appeal procedures and regulations. State requirements and specific Aetna plan details may vary by region and plan type. Muni Appeals maintains current procedures for all major insurance companies and state-specific regulations. Appeal timelines and requirements are based on Aetna's publicly available member and provider materials as of October 2025.