Aetna Prior Authorization Denial Appeal Template 2025 [Free Download]

Understanding Aetna Prior Authorization Denials

Prior authorization (PA) denials represent 28% of all Aetna claim denials—the second most common denial reason after medical necessity. For a comprehensive overview of all prior authorization denial reasons across insurers, see our complete prior authorization denial guide.

Aetna requires prior auth for:

• Specialist referrals (HMO plans)
• Advanced imaging (MRI, CT, PET scans)
• Surgeries and procedures
• Durable medical equipment (DME)
• Home health services
• Certain medications (managed by CVS Caremark)

Why Aetna Denies for Lack of Prior Auth

1. Service requires PA but none was obtained before treatment
2. PA was denied but service was provided anyway
3. PA expired before service was rendered
4. PA was for different service/diagnosis than what was billed
5. Emergency services not properly documented as emergent

When You Can Successfully Appeal Aetna PA Denials

✅ Scenario 1: Emergency or Urgent Services

Aetna's Policy: Prior authorization is not required for emergency services per federal law (Prudent Layperson Standard) and Aetna policy.

How to Appeal:

• Document the emergency nature of the situation
• Cite Aetna Clinical Policy Bulletin: Emergency Services (CPB 0500)
• Include clinical notes showing urgency

Example: Patient presented with severe chest pain. EKG performed emergently without PA. Appeal argues Prudent Layperson would consider this emergency, exempting PA requirement.

✅ Scenario 2: Administrative Barriers

Aetna's Policy: If provider made good-faith effort to obtain PA but faced administrative barriers, Aetna may grant retroactive authorization.

How to Appeal:

• Document PA request attempts (fax confirmations, phone logs)
• Show Aetna's system was unavailable or unresponsive
• Demonstrate patient would suffer harm if service delayed

Example: Provider submitted PA request 5 business days before procedure. Aetna didn't respond despite follow-up calls. Procedure performed to prevent patient deterioration. Appeal includes fax logs and phone records.

✅ Scenario 3: Continuity of Care

Aetna's Policy: For patients transitioning to Aetna from another insurer, services already in progress may qualify for retroactive PA.

How to Appeal:

• Show treatment started under previous insurer
• Demonstrate interruption would harm patient
• Request continuity of care exception

Example: Patient undergoing chemotherapy series changed employers mid-treatment. New Aetna plan requires PA for chemo. Appeal requests retroactive PA based on continuity of care.

✅ Scenario 4: PA Obtained But Not Linked

Aetna's Policy: Sometimes PA is obtained but not properly linked to the claim during processing.

How to Appeal:

• Provide PA approval number and date
• Include copy of PA approval letter
• Request claim reprocessing with PA linked

Example: PA obtained (approval #123456) but claim denied. Appeal includes PA letter and requests manual linkage.

❌ When Appeals Are Unlikely to Succeed

• Elective procedure with no emergency circumstances
• No attempt to obtain PA before service
• Provider knew PA was required but chose not to obtain it
• Patient was stable and service could have been delayed for PA

Aetna Prior Authorization Appeal Template

Use this template as a starting point. Customize based on your specific situation.

[Your Practice Letterhead]
[Date]

Aetna Appeals Department
P.O. Box 14463
Lexington, KY 40512-4463

RE: Appeal of Prior Authorization Denial
    Patient: [Patient Name], DOB: [Date]
    Member ID: [Aetna ID]
    Claim Number: [Claim #]
    Date of Service: [DOS]
    CPT Code(s): [Code]
    Denial Reason: "Prior authorization not obtained"

Dear Aetna Medical Review Team,

I am writing to appeal the denial of the above-referenced claim due to lack of
prior authorization. I respectfully request retroactive authorization based on
[select appropriate justification]:

☐ EMERGENCY/URGENT SERVICES (Check box if applicable)
☐ ADMINISTRATIVE BARRIERS (Check box if applicable)
☐ CONTINUITY OF CARE (Check box if applicable)
☐ PA OBTAINED BUT NOT LINKED (Check box if applicable)

CLINICAL BACKGROUND:

Patient: [Name], [Age], with [diagnosis]
Service Provided: [Description of service]
Date of Service: [Date]
Medical Necessity: [Brief statement of why service was needed]

JUSTIFICATION FOR RETROACTIVE AUTHORIZATION:

[Choose the section that applies to your case]

--- FOR EMERGENCY SERVICES ---

This service qualified as emergency treatment and was exempt from prior
authorization requirements per:

1. EMERGENCY CIRCUMSTANCES
   On [date], patient presented with [symptoms] requiring immediate intervention.
   Clinical presentation included:
   - [Vital sign abnormality, e.g., "BP 180/110"]
   - [Severe symptoms, e.g., "chest pain radiating to left arm"]
   - [Risk of serious adverse outcome if delayed]

   Under the Prudent Layperson Standard (defined in Aetna's Emergency Services
   Policy CPB 0500), a layperson with average knowledge of health and medicine
   would reasonably expect that delaying care could result in:
   - Serious jeopardy to patient health
   - Serious impairment to bodily functions
   - Serious dysfunction of bodily organ or part

2. COMPLIANCE WITH FEDERAL LAW
   The Emergency Medical Treatment and Labor Act (EMTALA) and Aetna's own
   emergency services policy prohibit requiring prior authorization for
   emergency services.

3. CLINICAL DOCUMENTATION
   Attached medical records demonstrate the emergent nature of this presentation.
   [Provider name], a board-certified [specialty], determined immediate
   intervention was medically necessary.

CONCLUSION:
Prior authorization was not required for this emergency service. I request
payment of the claim per Aetna's Emergency Services Policy (CPB 0500).

--- FOR ADMINISTRATIVE BARRIERS ---

Despite good-faith efforts to obtain prior authorization, administrative
barriers prevented timely approval:

1. DOCUMENTED PA REQUEST ATTEMPTS
   - [Date]: Submitted PA request via Aetna provider portal (confirmation #[X])
   - [Date]: Called Aetna PA line (reference #[X], spoke with [name])
   - [Date]: Faxed PA request to [fax number] (fax confirmation attached)
   - [Date]: Re-submitted via portal due to no response

2. AETNA'S FAILURE TO RESPOND
   Despite [X] contact attempts over [X] business days, Aetna did not provide
   PA decision before scheduled service date. Aetna's PA policy states decisions
   will be provided within [X] business days. This timeline was not met.

3. MEDICAL NECESSITY FOR PROCEEDING
   Delaying the service would have resulted in:
   - [Clinical deterioration, e.g., "progression of disease"]
   - [Patient harm, e.g., "increased pain and disability"]
   - [Increased cost, e.g., "likely ED visit or hospitalization"]

   As the treating physician, I determined proceeding without PA was in the
   patient's best medical interest given Aetna's administrative delays.

4. AETNA POLICY SUPPORT
   Aetna's Provider Manual (Section [X]) states: "Services may qualify for
   retroactive PA when provider demonstrates good-faith effort to obtain PA but
   faced administrative barriers beyond provider control."

CONCLUSION:
I respectfully request retroactive prior authorization based on documented
good-faith efforts and Aetna's administrative delays. Attached documentation
includes PA request confirmations and clinical notes.

--- FOR CONTINUITY OF CARE ---

Patient requires continuity of existing treatment that began under prior
insurance coverage:

1. TREATMENT HISTORY
   Patient began treatment for [condition] on [date] under [previous insurer].
   Treatment plan includes [description], expected duration [timeframe].

2. TRANSITION TO AETNA
   Patient's insurance changed to Aetna effective [date] due to [job change/
   plan change]. At time of insurance transition, patient was actively receiving
   treatment and showing clinical improvement.

3. MEDICAL NECESSITY FOR CONTINUITY
   Interrupting treatment to obtain PA would have caused:
   - [Clinical setback, e.g., "relapse of symptoms"]
   - [Treatment delay, e.g., "gap in chemotherapy affecting outcomes"]
   - [Patient harm, e.g., "surgical delay increasing complication risk"]

4. AETNA CONTINUITY OF CARE POLICY
   Aetna's Transition of Care policy states: "Members transitioning from another
   health plan may continue active treatment with non-network providers for up to
   [X] days while PA is obtained." This service falls within that timeframe.

CONCLUSION:
I request retroactive PA under Aetna's Transition of Care policy to maintain
continuity of medically necessary treatment.

--- FOR PA OBTAINED BUT NOT LINKED ---

Prior authorization WAS obtained but not properly linked to this claim:

PA APPROVAL DETAILS:
- Approval Number: [PA #]
- Approval Date: [Date]
- Approved Services: [Description]
- Valid Dates: [Start date] through [End date]

CLAIM PROCESSING ERROR:
The denied claim falls within the approved PA timeframe and matches the
approved service. This appears to be a claim processing error where the PA
was not properly linked during adjudication.

REQUEST:
Please reprocess the claim with PA #[number] linked. Copy of PA approval letter
is attached.

---

SUPPORTING DOCUMENTATION:

Enclosed please find:
☐ PA request confirmation(s)
☐ Phone log of PA attempts
☐ Fax confirmation(s)
☐ Clinical notes documenting medical necessity
☐ PA approval letter (if applicable)
☐ Previous insurer's coverage documentation (for continuity of care)
☐ Aetna CPB citation supporting coverage

I am available to discuss this case or provide additional information. Please
contact me at [phone] or [email].

Respectfully,

[Signature]
[Provider Name, Credentials]
NPI: [Number]
Tax ID: [Number]

Enclosures: [List attachments]

How to Strengthen Your Aetna PA Appeal

1. Cite Specific Aetna Policies

Don't say: "The service should be covered."

Do say: "Per Aetna Clinical Policy Bulletin #0872 (Advanced Imaging), MRI is covered for [diagnosis] when [criteria met]. Patient meets criteria as evidenced by [clinical findings]."

Key Aetna Policy Documents to Reference:

• Clinical Policy Bulletins (CPBs): Aetna's coverage policies by service type
• Provider Manual: Administrative policies including PA procedures
• Emergency Services Policy (CPB 0500): Defines emergency care standards
• Transition of Care Policy: Continuity of care provisions

Find current CPBs at: Aetna provider portal → Clinical Resources → Clinical Policy Bulletins

2. Document Timeline of Events

Create a clear timeline showing:

• When PA was requested (if applicable)
• When service was needed
• When patient would have suffered harm if delayed
• All communication attempts with Aetna

Example Timeline:

March 1: Patient diagnosed with [condition], service scheduled for March 15
March 3: PA request submitted via Aetna portal (confirmation #12345)
March 8: No PA decision received, called Aetna (reference #67890)
March 10: Faxed PA request (fax confirmation attached)
March 13: Still no decision, patient's condition worsening
March 15: Service performed to prevent clinical deterioration
March 20: PA retroactively denied
March 25: Claim denied for lack of PA
April 1: This appeal submitted

3. Include Clinical Evidence

Strengthen your appeal with:

• Progress notes showing worsening without treatment
• Test results demonstrating severity
• Specialist recommendations supporting need for service
• Photos (if applicable, e.g., wound deterioration)
• Emergency room records (if patient would have gone to ER if service delayed)

4. Calculate Financial Impact

Show Aetna the cost comparison:

Example for denied MRI:

Denied MRI (outpatient): $800
Alternative if PA delayed:
- 2 ED visits for worsening pain: $3,000
- Emergency MRI (higher cost): $2,000
- Specialist consultations: $600
Total cost to Aetna if delayed: $5,600

Approving this appeal saves Aetna $4,800

Aetna's medical directors respond to cost-benefit arguments.

5. Request Peer-to-Peer Review

If your written appeal is denied, request a peer-to-peer review:

"I request the opportunity for peer-to-peer discussion with Aetna's medical
director to discuss this case. As the treating physician, I can provide
clinical context that may not be apparent from documentation alone."

During peer-to-peer:

• Have patient chart ready
• Emphasize clinical urgency
• Ask reviewer's rationale for denial
• Address concerns directly
• Follow up with written summary

Peer-to-peer reviews have 75%+ success rate for PA appeals.

Aetna Prior Authorization Appeal FAQ

How long do I have to appeal an Aetna PA denial?

Answer: 180 days from the denial date for most plans. Medicare Advantage Aetna plans have shorter timeframes (60 days). Check your denial letter for specific deadline.

Pro tip: File within 30 days for fastest resolution. Aetna processes recent appeals first.

Can I get retroactive PA for elective services?

Unlikely. Aetna rarely grants retroactive PA for truly elective services where:

• Service could have been delayed for PA
• Patient was clinically stable
• No emergency circumstances existed
• Provider simply didn't request PA

Better strategy: For future elective services, always obtain PA before treatment.

What if Aetna's PA system was down?

Document everything:

• Screenshot of system error message
• Note date/time you attempted to access system
• Call Aetna's PA line and get reference number for system outage
• Document any communication from Aetna acknowledging system issues

In your appeal: "On [date], Aetna's prior authorization system was unavailable (error message attached). Called PA hotline (ref #[X]) and was advised system was down. Given clinical urgency and system unavailability beyond my control, I proceeded with medically necessary service and request retroactive PA."

Does Aetna accept faxed PA appeals?

Yes. Aetna accepts appeals via:

• Mail: P.O. Box 14463, Lexington, KY 40512-4463
• Fax: 1-859-425-3379 (most convenient)
• Online: Aetna provider portal (Appeals section)

Recommendation: Fax for fastest processing, then mail original with tracking.

What information does Aetna need for PA appeals?

Minimum required:

1. Patient name, DOB, member ID
2. Claim number
3. Date of service
4. CPT/HCPCS code
5. Denial reason
6. Clinical justification for service
7. Provider NPI and signature

Strengthens appeal: 8. PA request documentation (if applicable) 9. Clinical notes 10. Relevant Aetna CPB citations 11. Peer-reviewed evidence 12. Cost-benefit analysis

How long does Aetna take to decide PA appeals?

Standard: 30 days Expedited: 72 hours (if delay would jeopardize patient health) Actual timeline: Most decisions in 15-25 days

Request expedited review if:

• Patient has active/worsening condition
• Delay would cause serious harm
• Service already provided and patient needs ongoing treatment

Can I bill the patient if Aetna denies my PA appeal?

It depends:

In-network providers: Usually NO. Your contract likely prohibits balance billing for denied claims. You must accept Aetna's decision or pursue further appeals.

Out-of-network providers: Maybe, depending on state law and whether you provided advance notice to patient.

Best practice:

1. Get Advance Beneficiary Notice (ABN) signed BEFORE service if you suspect PA may be denied
2. ABN informs patient they may be financially responsible
3. Even with ABN, some states prohibit surprise billing

Consult your contract and local billing regulations before billing patients.

Automate Your Aetna Prior Authorization Appeals

Writing comprehensive PA appeals like the template above typically takes 30-45 minutes per denial. For practices handling multiple Aetna denials monthly, this administrative burden becomes unsustainable.

Muni Health automates Aetna prior authorization appeals with:

• 89% success rate on Aetna PA appeals
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• Automatic CPB citation: AI finds relevant Clinical Policy Bulletins
• Custom justifications: Tailored to emergency, administrative barrier, or continuity of care scenarios
• Timeline generation: Creates clear sequence of events

Start 3 Free Aetna Appeals →

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This guide reflects 2025 Aetna appeal procedures. Requirements may vary by state and specific plan type. Muni Appeals maintains up-to-date procedures for all Aetna plans.