How to appeal an Elevance Health thyroid eye disease (ted) — tepezza (teprotumumab) and igf-1r therapy 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.

Elevance Health-specific note: Operates Anthem BCBS in 14 states. Owns Carelon (formerly AIM) which manages utilization for specialty drugs and advanced imaging. State complaint route is to the state insurance department where the policy was issued.

What Elevance Health's policy requires for thyroid eye disease (ted) — tepezza (teprotumumab) and igf-1r therapy

Cited policy: Anthem / BCBSA Evidence Positioning System: Teprotumumab for Thyroid Eye Disease

EUGOGO moderate-to-severe TED; CAS-based activity threshold; quantitative proptosis measurement; prior systemic glucocorticoid trial or documented contraindication; euthyroid status; safety baselines (audiogram, glucose / A1c); excludes pregnancy.

How Elevance Health denies thyroid eye disease (ted) — tepezza (teprotumumab) and igf-1r therapy — and how to counter it

Where Elevance Health pushes back: 1) Documentation insufficient on CAS / proptosis; 2) Mild TED — selenium recommended first; 3) Steroid trial inadequate; 4) Plan exclusion of specialty biologics.

Counter-arguments that hold up: Submit complete CAS 7-item itemized score and Hertel measurements with base reading. For mild TED selenium is first-line per EUGOGO (Marcocci NEJM 2011) — only escalate to Tepezza for moderate-to-severe. Document failed methylpred or contraindication. For 'plan exclusion' confirm administration under medical (not pharmacy) benefit using HCPCS J3241; reroute. Cite OPTIC + AAO PPP 2022.

What Elevance Health typically denies for thyroid eye disease (ted) — tepezza (teprotumumab) and igf-1r therapy

Across Elevance Health's commercial and Medicare books, denials cluster around a small number of patterns. For thyroid eye disease (ted) — tepezza (teprotumumab) and igf-1r therapy, expect:

• Step therapy
• Medical necessity for biologics
• Out-of-network for behavioral health
• Bariatric surgery prior auth

Treatments most often denied in this category

These are the thyroid eye disease (ted) — tepezza (teprotumumab) and igf-1r therapy treatments most often flagged for prior auth, step therapy, or medical necessity review:

• Tepezza standard course
• Tepezza re-treatment
• Tepezza chronic-stable
• IV methylprednisolone
• Oral prednisone
• Orbital radiotherapy

How to submit the appeal to Elevance Health

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 Elevance Health cited in the denial.
3. File the appeal through Elevance Health's portal (members: https://www.anthem.com ; providers: https://providers.anthem.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 IN, 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 Elevance Health's prior-authorization criteria by drug: Elevance Health PA criteria on ApprovalHelp.