Why Aetna Denies Inpatient Rehabilitation Facility (IRF)
Patient does not require 3 hours/day therapy intensity
Skilled nursing facility is appropriate alternative
Medical complexity does not warrant IRF level
Know Aetna's Criteria
Aetna uses their own Clinical Policy Bulletins (CPBs) and InterQual criteria. CPBs are publicly available and numbered.
Key policies to know:
- Clinical Policy Bulletins (CPBs) are publicly available and numbered
- Uses eviCore for radiology and cardiology prior auth
- Known for detailed, evidence-based CPBs with specific criteria
- Precertification list updated annually
Building Your Medical Necessity Argument
Document ability to participate in 3+ hours/day of therapy
List qualifying diagnoses under the 60% rule
Note medical complexity requiring physician supervision
Explain why SNF level is insufficient for this patient
P2P Call Tips for Aetna
Reference the specific CPB number and criteria being met
Aetna CPBs are very detailed -- read them before the call
Address each specific criterion in the CPB during the P2P
Aetna medical directors are typically receptive to guideline-based arguments
Guidelines to Reference
- CMS IRF Coverage Requirements (60% Rule)
- InterQual Criteria for Rehabilitation Facility Admission
Relevant CPT Codes
Specialty: Physical Medicine & Rehabilitation
Want the full strategy?
The P2P Playbook covers payer-specific approaches for Inpatient Rehabilitation Facility (IRF) denied by Aetna -- plus 15 denial objections with word-for-word responses, what reviewers are actually thinking, and the 60-second prep framework. Written by a medical director who reviewed cases for major payers.
Get The P2P Playbook -- $39Get a personalized P2P script in 60 seconds
Enter your specific case details and our AI generates a structured prep script tailored to Aetna's criteria.