How to appeal an Aetna myasthenia gravis & cidp denial

The framework that applies to your appeal

Federal law gives you the right to a full and fair internal appeal, then an external review by an independent third party.

Aetna-specific note: Owned by CVS Health since 2018. CVS Caremark is the PBM. Aetna ASA administers self-funded ERISA plans. Meritain Health is Aetna's TPA brand.

What Aetna's policy requires for myasthenia gravis & cidp

Cited policy: Aetna CPB on Soliris (eculizumab) for Refractory AChR-Ab+ gMG

Anti-AChR-Ab+ generalized MG. MGFA class II-IV. Inadequate response to >=2 immunosuppressants OR chronic IVIG/PLEX dependence. MG-ADL >=6. Documented MenACWY + MenB vaccination >=2 wk pre-initiation OR concurrent antibiotic prophylaxis (FDA REMS). Treating neurologist. Reauth at 6 mo with MG-ADL improvement.

How Aetna denies myasthenia gravis & cidp — and how to counter it

Where Aetna pushes back: 1) Must try Vyvgart (cheaper FcRn) before C5 inhibitor; 2) Single IS trial insufficient — require ≥2; 3) Meningococcal vaccination not documented; 4) MG-ADL not high enough.

Counter-arguments that hold up: REGAIN (Howard Lancet Neurol 2017) — Phase 3 Soliris in AChR-Ab+ refractory gMG; supported FDA approval Oct 23, 2017 — first-in-class C5 inhibitor for MG. IST 2020 + AAN 2021 refractory definition is ≥1 IS inadequate response OR intolerance, OR chronic IVIG/PLEX dependence. C5 vs FcRn mechanism is not fungible — complement-mediated postsynaptic membrane damage in AChR-Ab+ MG specifically targeted. Submit MenACWY + MenB records or initiate concurrent. Cite disabling bulbar/respiratory items.

What Aetna typically denies for myasthenia gravis & cidp

Across Aetna's commercial and Medicare books, denials cluster around a small number of patterns. For myasthenia gravis & cidp, expect:

• UM-2575 medical necessity denials
• Prior auth absent
• Step therapy on specialty drugs
• Out-of-network ER reduction

Treatments most often denied in this category

These are the myasthenia gravis & cidp treatments most often flagged for prior auth, step therapy, or medical necessity review:

• Soliris (MG)
• Ultomiris (MG)
• Vyvgart IV (MG)
• Vyvgart Hytrulo (MG)
• Rystiggo (MG)
• Zilbrysq (MG)

How to submit the appeal to Aetna

1. Read the denial letter — note the exact denial reason code and the appeal deadline (180 days from the date on the letter).
2. Gather supporting documentation: physician letter of medical necessity, relevant clinical notes, peer-reviewed citations supporting the treatment for your indication, and the policy or coverage document Aetna cited in the denial.
3. File the appeal through Aetna's portal (members: https://www.aetna.com ; providers: https://www.aetnaprovider.com). Standard decision returns within 30 days; expedited urgent appeals return within 72 hours.
4. If denied again, request external review by an independent reviewer within 4 months of the final internal denial. In CT, the state insurance department coordinates external review for fully-insured plans; ERISA self-funded plans use a federal external review through DOL/EBSA.

Clinician or prior-auth team handling this on the practice side? See Aetna's prior-authorization criteria by drug: Aetna PA criteria on ApprovalHelp.