How to appeal a Highmark cardiac devices & procedures 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.

Highmark-specific note: Operates BCBS in PA (western), WV, DE, NY (western). Owns Allegheny Health Network.

What Highmark's policy requires for cardiac devices & procedures

Cited policy: BCBS — Transcatheter Mitral Valve Repair / Anthem clinical guideline TEER

COAPT phenotype: EF 20-50%, severe secondary MR, NYHA II-IVa on GDMT >=3 months, prohibitive surgical risk. Heart Team evaluation per NCD 20.34.

How Highmark denies cardiac devices & procedures — and how to counter it

Where Highmark pushes back: 1) Functional MR investigational; 2) EF outside COAPT window (20-50%); 3) GDMT not optimized; 4) Surgical candidate determination unclear.

Counter-arguments that hold up: Demonstrate COAPT phenotype: EF, EROA, regurgitant volume, NYHA, GDMT trial. Cite COAPT NEJM 2018 + NCD 20.34 + 2020/2023 VHD Guideline Class IIa for secondary MR. Heart Team consensus with surgical risk attestation; STS-PROM >=8% or prohibitive risk.

What Highmark typically denies for cardiac devices & procedures

Across Highmark's commercial and Medicare books, denials cluster around a small number of patterns. For cardiac devices & procedures, expect:

• Prior auth on biologics
• PA on advanced imaging
• OON balance bills

Treatments most often denied in this category

These are the cardiac devices & procedures treatments most often flagged for prior auth, step therapy, or medical necessity review:

• ICD (primary)
• ICD (secondary)
• CRT-D / CRT-P
• Watchman LAAC
• TAVR (high risk)
• TAVR (intermediate)

How to submit the appeal to Highmark

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 Highmark cited in the denial.
3. File the appeal through Highmark's portal (members: https://www.highmark.com ; providers: https://www.highmark.com/provider). 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 PA, 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 Highmark's prior-authorization criteria by drug: Highmark PA criteria on ApprovalHelp.