CVS Health / Aetna MA

CVS Health / Aetna MA operates Medicare Advantage contract H5521 as a HMO plan, one of hundreds of MA organizations whose prior authorization and claim-denial behavior is tracked through CMS Office of Inspector General audits and the KFF Medicare Advantage analysis. In the most recent reporting window, CVS Health / Aetna MA processed 980,000 prior authorization requests, approving 870,240 and denying 109,760 - a denial rate of 11.2%. Prior authorization is the process by which Medicare Advantage plans require plan-level approval before covering specific services, medications, or procedures, a workflow that does not exist in traditional fee-for-service Medicare.

Of the denials issued by CVS Health / Aetna MA, 16,464 were appealed by beneficiaries or providers, and 12,348 of those appeals were overturned - an overturn rate of 75.0%. A high overturn rate is meaningful because the CMS Office of Inspector General flagged it as a sign that initial denials may have been issued incorrectly or based on internal clinical criteria stricter than traditional Medicare's coverage rules. When an appeal reverses a denial, the plan ultimately pays for the care it initially refused, which suggests the original denial was not supported when reviewed more carefully. For CVS Health / Aetna MA specifically, the high overturn rate indicates that beneficiaries who do appeal are very likely to win.

Practical takeaway for beneficiaries enrolled in or considering CVS Health / Aetna MA: if you receive a prior authorization denial, you have formal appeal rights under CMS Medicare Advantage rules, first through the plan itself, then to an independent review entity, and further through administrative law judges if needed. Do not abandon the appeal because the plan's first decision was unfavorable; the nationwide overturn pattern strongly suggests that appealing is often worthwhile. Data here reflects aggregate plan behavior, not individual case outcomes, your specific denial will depend on the service requested, clinical documentation, and CMS national coverage determinations. This page is informational only and does not constitute medical, financial, or insurance advice. Consult your plan documents, CMS.gov, or a State Health Insurance Assistance Program (SHIP) counselor for guidance specific to your situation.