Form Gr-68765 (2-12) - Request For An Appeal Of An Aetna Medicare Advantage Plan Denial Page 2
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2Important Note: Expedited Decisions
If you or your physician believes that waiting 30 days for a standard decision could seriously harm your
life, health, or ability to regain maximum function, you can ask for an expedited (fast) decision. If your
physician indicates that waiting 30 days could seriously harm your health, we will automatically give you
a decision within 72 hours. If you do not obtain your physician's support for an expedited appeal, we will
decide if your case requires a fast decision.
CHECK THIS BOX IF YOU BELIEVE YOU NEED A DECISION WITHIN 72 HOURS. If you have
a supporting statement from your physician, attach it to this request.
Please explain your reasons for appealing.
Attach additional pages, if necessary. Attach any additional information you believe may help your case,
such as a statement from your physician and relevant medical records. You may want to refer to the
explanation we provided in the Notice of Denial of Medical Coverage or Notice of Denial of Payment.
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Signature of person requesting the appeal
Date
(the enrollee, or the enrollee’s prescriber or representative)
A Medicare Advantage organization with a Medicare contract. A Medicare approved Part D Sponsor.
Y0001_M_AG_FM_11151 CMS Approved 12/08/11
Page 2 of 2
GR-68765 (2-12) R-POD
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