How to appeal a Highmark endocrine (non-diabetes) 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 endocrine (non-diabetes)

Cited policy: BCBS Pharmacy Policy — Crinecerfont (Crenessity)

Classic CAH genotype-confirmed. Adolescents and adults. Glucocorticoid dose minimization goal.

How Highmark denies endocrine (non-diabetes) — and how to counter it

Where Highmark pushes back: 1) 'Experimental / new drug'; 2) GC dose 'adequate'; 3) Pediatric coverage limitations.

Counter-arguments that hold up: FDA approved Dec 2024 — first new CAH treatment in decades. Cite CAHtalyst Adult + Pediatric trials. Endocrine Society 2018 CAH guidelines endorse glucocorticoid minimization goal. Document supraphysiologic GC dose + adverse effects (Cushingoid features, BMD loss, growth impairment in peds, metabolic syndrome).

What Highmark typically denies for endocrine (non-diabetes)

Across Highmark's commercial and Medicare books, denials cluster around a small number of patterns. For endocrine (non-diabetes), expect:

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

Treatments most often denied in this category

These are the endocrine (non-diabetes) treatments most often flagged for prior auth, step therapy, or medical necessity review:

• TRT
• Tepezza (TED)
• Crenessity (CAH)
• Isturisa (Cushing's)
• Recorlev
• Mycapssa

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.