# Faultprint Assessment Draft: Aetna

## Status

Draft generated from the calibrated v3 operating/postmortem crosswalk and the client-output eligibility gate.

This draft is findings-only. It does not recommend actions, predict failure, assert illegality, or claim that the institution has failed.

## Corpus Position

- Institution: Aetna
- Sector: Health insurance
- Client-eligible findings included: 4
- Caveated findings included: 3

## Pathology Mix

- Classification Gatekeeping: 2
- Contestability Lag: 1
- Access Interruption Before Review: 1

## Resemblance Mix

- moderate_resemblance: 4

## Findings

### Finding 1: Access Interruption Before Review

Condition: External review available for eligible denials

Resemblance band: moderate_resemblance

Output status: client_ready

Finding statement: Operating row shows a condition also present in postmortem libraries, but current public evidence is not enough to treat it as high exposure.

Evidence anchor: Aetna states certain coverage denials can be reviewed by independent physician reviewers after plan appeal process exhaustion.

Falsification evidence: Eligibility rules or outcome data showing external review is rarely available or ineffective would weaken this mitigant.

Boundary: Does not apply to every denial.

### Finding 2: Classification Gatekeeping

Condition: Appeals apply to medical necessity and coverage criteria decisions

Resemblance band: moderate_resemblance

Output status: client_ready_with_caveat

Finding statement: Operating row shows a condition also present in postmortem libraries, but current public evidence is not enough to treat it as high exposure.

Evidence anchor: Aetna states appeals apply when a decision was based on medical necessity payment policy or experimental/investigational coverage criteria.

Falsification evidence: Decision logs showing these criteria are not used in adverse determinations would downgrade exposure.

Boundary: Does not prove decisions are wrong or improperly made.

### Finding 3: Classification Gatekeeping

Condition: Clinical Policy Bulletins define policy while decisions are case-by-case

Resemblance band: moderate_resemblance

Output status: client_ready_with_caveat

Finding statement: Operating row shows a condition also present in postmortem libraries, but current public evidence is not enough to treat it as high exposure.

Evidence anchor: Aetna states CPBs define clinical policy while medical necessity determinations are made case by case.

Falsification evidence: Review records showing determinations are purely mechanical or fully governed by plan terms would narrow this finding.

Boundary: Does not prove inconsistency or reviewer error.

### Finding 4: Contestability Lag

Condition: Coverage decisions and appeals are public member workflows

Resemblance band: moderate_resemblance

Output status: client_ready_with_caveat

Finding statement: Operating row shows a condition also present in postmortem libraries, but current public evidence is not enough to treat it as high exposure.

Evidence anchor: Aetna states members may request a coverage decision and may appeal if the answer is no.

Falsification evidence: Appeal records showing the path is inaccessible or routinely ineffective would weaken this mitigant.

Boundary: Does not prove appeals are substantively effective.

## Internal Exclusions

No internal revise/hold rows were included in this report draft.

## Report Boundary

This draft is based on the reviewed corpus and the current Faultprint evidence libraries. It identifies structural conditions and evidence requirements. It is not a legal opinion, audit conclusion, compliance certification, or prediction.