What the Investigation Is About
The Schall Law Firm, a national litigation firm based in Los Angeles, is actively investigating claims on behalf of Aetna Medicare Advantage policyholders. The investigation targets CVS Health Corporation (“CVS”) for alleged breach of contract and related violations of state laws. Specifically, the firm examines whether CVS/Aetna wrongfully denied prior authorizations for post-acute care — that is, medical care needed after a patient is discharged from a hospital.
Post-acute care includes services such as skilled nursing, rehabilitation, and home health care. These services are critical for recovery. Denying them without proper medical review can put patients at serious risk. The Schall Law Firm contends that CVS/Aetna may have done exactly that — and at scale.
How CVS/Aetna Used AI to Deny Claims
The Role of Artificial Intelligence in Prior Authorization
At the center of this investigation is CVS/Aetna’s alleged use of an artificial intelligence program to screen and deny prior authorization requests. Under the terms of their contracts with policyholders, CVS/Aetna must ensure that qualified medical professionals review each prior authorization request before reaching a decision.
However, evidence suggests that CVS bypassed this requirement. Instead of routing requests to licensed clinicians first, the company reportedly used an AI tool to vet claims before any medical professional evaluated them. This approach raises serious legal and ethical concerns. It may also directly contradict the contractual obligations CVS owes to its policyholders.
The Impact on Post-Acute Care Patients
Patients who rely on Aetna Medicare Advantage plans often need post-acute care during their most vulnerable moments. Therefore, improper claim denials do not merely create administrative burdens — they interrupt essential healthcare. Many policyholders may have been forced to pay out of pocket, delay recovery care, or forgo necessary treatment altogether. These outcomes highlight why this investigation matters.
Senate Scrutiny Over CVS AI Practices
CVS’s use of artificial intelligence in claims processing has drawn attention beyond the courtroom. The United States Senate recently scrutinized the company’s conduct regarding its AI-driven prior authorization system. Lawmakers have raised concerns that AI tools used for claims decisions may not account for individual patient circumstances. Furthermore, they may systematically disadvantage Medicare beneficiaries who depend on timely care decisions.
This congressional attention adds significant weight to the ongoing legal investigation. It also signals that regulatory and legislative action could follow.
Who Qualifies to Join the Investigation
Eligibility Period and Criteria
You may be eligible to participate in this investigation if you meet the following criteria:
- You are, or were, an Aetna Medicare Advantage plan policyholder.
- Your prior authorization request for post-acute care was denied.
- The denial occurred during the period from November 2019 through the present.
If these conditions apply to you, the Schall Law Firm encourages you to take action. Joining the investigation gives you the opportunity to assert your rights and seek accountability for improper claim denials.
Why Policyholders Should Act Now
Your Rights as a Medicare Advantage Policyholder
Medicare Advantage plans carry specific contractual obligations. When insurers like CVS/Aetna fail to honor those obligations, policyholders have legal recourse. Additionally, statutes of limitations may restrict how long you have to file a claim. Acting promptly preserves your right to participate.
The Bigger Picture for Healthcare Accountability
This case is part of a broader national conversation about the role of AI in healthcare decision-making. As insurers increasingly rely on automation, questions about transparency, fairness, and patient safety continue to grow. Consequently, legal action like this investigation serves not only individual claimants but also sets important precedents for the entire industry.
If CVS/Aetna’s use of AI resulted in your post-acute care claim being denied, you deserve answers — and possibly compensation. Reach out to the Schall Law Firm today to learn more about your options.
