How to appeal a Aetna denial
Your appeal path depends on which kind of Aetna plan you have. Find yours below — deadlines differ, and deadlines are everything.
Medicare Advantage
You have a Medicare plan run by a private insurer (an “MA” or “Part C” plan) — the card says Medicare Advantage, and the insurer is a company like UnitedHealthcare, Humana, or Aetna.
Level 1 — Plan reconsideration
File within 65 days. The plan must use a different reviewer; medical denials need a physician reviewer.
Level 2 — Independent Review Entity (automatic)
If the plan says no again, it MUST forward your case to an outside reviewer automatically. You do nothing.
Level 3 — Administrative Law Judge
60 days to request a hearing if the amount in dispute meets the threshold.
Medicaid
Your coverage is Medicaid or CHIP — often through a managed care company (Centene, Molina, UnitedHealthcare Community Plan, and others run state Medicaid plans).
Step 1 — Plan appeal (managed care)
60 days to file with your managed care plan. Decision in 30 days, 72 hours expedited.
Step 2 — State fair hearing
Impartial state hearing officer, typically within 90–120 days of the plan's decision. You can represent yourself, bring anyone, and testify.
Aid paid pending
Appeal within 10 days of the notice and current services generally continue until the decision.
ACA / Marketplace Plans
You bought your plan on healthcare.gov or a state exchange, or you have an individual (non-employer) plan regulated by the Affordable Care Act.
Step 1 — Internal appeal
180 days to file. Plan decides in 30 days (pre-service) or 60 days (post-service); 72 hours if urgent.
Step 2 — External review
State or federal HHS process depending on your state. Independent, binding, 4 months to file.
In parallel — state insurance department complaint
Your state DOI takes consumer complaints and can pressure insurers on process violations.
Employer Plans (ERISA)
Your insurance comes through a private-sector job — yours or a family member's. Most working-age Americans with employer coverage are in an ERISA plan, even when a big-name insurer administers it.
Step 1 — Internal appeal
180 days to file. New decision-maker, no deference to the original denial, qualified medical reviewer for clinical denials.
Step 2 — External review
Independent review organization for medical-judgment denials. Binding on the plan. 4 months to file.
Step 3 — Federal court (ERISA § 502)
Lawsuit to recover benefits. The record you built in the internal appeal is usually the ONLY evidence the court sees — build it well.