Insurance Denial Report

Aetna (CVS Health) denies 17.2% of claims.
Here's how patients are fighting back.

Data from the 2023 CMS Marketplace Transparency Report. The national average is 19.1%. Aetna denies claims at 1.9 points below average.

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17.2%
Claims denied
1.9pts
Below national avg
65%
Appeals overturned
19
States they operate in

What Aetna (CVS Health)'s denial rate means for patients

Aetna (CVS Health) has a health insurance claim denial rate of 17.2%, which is slightly below the national average of 19.1%. This means that while some claims may be denied, a significant number of patients are still able to successfully navigate the appeals process. Understanding this denial rate can empower patients to take action when faced with a claim denial, knowing that they are not alone in this journey.

The encouraging news is that 65% of appeals are overturned in favor of patients, highlighting that many denials can be successfully challenged. Patients have rights and options when it comes to their healthcare coverage. If you find yourself facing a denial, remember that you have the ability to appeal and advocate for the care you need. With Aetna's denial rate being below average, there is a strong chance that your appeal could lead to a positive outcome.

What Aetna denies most often

Denial rates by treatment category, compared to the national average (19.1%).

GLP-1 Medications (Ozempic, Wegovy)
vs. ~19% avg
28%
Specialty Medications
vs. ~19% avg
22%
Mental Health
vs. ~19% avg
18%
MRI / CT Scans
vs. ~19% avg
12%

Aetna's most common denial reasons

  1. 1Not medically necessary
  2. 2Step therapy requirements
  3. 3Prior authorization absent
  4. 4Non-covered benefit
  5. 5Clinical documentation insufficient

How to appeal a Aetna (CVS Health) denial

If your claim with Aetna (CVS Health) is denied, you can take specific steps to appeal the decision. Start by sending your appeal to the address provided in your denial letter, ensuring you do this within the typical 180-day deadline. It's crucial to request the clinical criteria that Aetna used to make their decision, as this information can guide your appeal. Additionally, consider requesting a peer-to-peer review with Aetna's medical director, which can provide a more in-depth examination of your case and increase the chances of a favorable outcome.

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Frequently asked questions about Aetna (CVS Health) denials

How long do appeals take with Aetna?
Appeals with Aetna typically take about 30 to 60 days for a decision. However, the timeline can vary based on the complexity of the case and the specific circumstances surrounding the denial.
What documentation helps most in an appeal?
To strengthen your appeal, include relevant medical records, a letter from your healthcare provider detailing the necessity of the treatment, and any supporting documents that demonstrate why the denial should be overturned.
What should I do if my first appeal is denied?
If your first appeal is denied, don't be discouraged. You can file a second appeal, often referred to as a 'level two appeal.' Review the denial letter for any specific reasons and gather additional evidence or documentation to support your case.
Do I need an attorney for my appeal with Aetna?
While hiring an attorney can be beneficial, especially for complex cases, it is not always necessary for appealing a denial with Aetna. Many patients successfully navigate the appeals process on their own by following the guidelines and gathering proper documentation.
GLP-1 appeal guide →MRI denial guide →How to appeal guide →Full resource center →

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