Aetna Denied Your Specialist Referral?
Aetna (CVS Health) denies 16.7% of claims on average. But 49% of appeals succeed when patients fight back. Your specialist referral denial may have grounds for a successful appeal.
Why Aetna Denies Specialist Referral
Primary care can manage the condition
Out-of-network specialist not covered
Referral authorization expired or not obtained
Aetna's Common Denial Tactics
Citing lack of medical necessity without reviewing full records
Applying step therapy requirements retroactively
Using internal guidelines stricter than Medicare standards
How to Win Your Specialist Referral Appeal
PCP letter explaining why specialist care is needed
Documentation of failed primary care treatment
Evidence no in-network specialist is available for the condition
Laws That Protect You
ACA network adequacy requirements
State any-willing-provider laws
No Surprises Act for emergency specialist care
Tips for Appealing to Aetna
Request the specific clinical criteria used to deny your claim
Ask for a peer-to-peer review between your doctor and their medical director
File with your state insurance department if internal appeal fails
Ready to Fight Your Specialist Referral Denial?
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This information is for educational and informational purposes only. It does not constitute legal or medical advice. Statistics cited are from publicly available sources including KFF, HHS OIG, and state insurance department data. Individual results may vary. Consult a qualified professional before taking action on your specific situation.