How to appeal a Highmark eosinophilic esophagitis (eoe) 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 eosinophilic esophagitis (eoe)

Cited policy: BCBS Esophageal Dilation for EoE Fibrostenotic Disease

EREFS stricture grade >=1 OR esophageal diameter <13 mm OR documented food impaction. Performed concurrent with or after anti-inflammatory therapy initiation. Maximum 3 sessions per 6 mo without therapy escalation review.

How Highmark denies eosinophilic esophagitis (eoe) — and how to counter it

Where Highmark pushes back: 1) Conservative anti-inflammatory therapy first; 2) Insufficient stricture severity.

Counter-arguments that hold up: ACG 2020 + AGREE 2018 — dilation treats fibrostenotic complication; without concurrent anti-inflammatory therapy strictures recur (Schoepfer Gastroenterology 2013 — diagnostic delay drives stricture risk). Submit EREFS + esophageal diameter measurement + impaction history. CPT 43220/43249/43233.

What Highmark typically denies for eosinophilic esophagitis (eoe)

Across Highmark's commercial and Medicare books, denials cluster around a small number of patterns. For eosinophilic esophagitis (eoe), expect:

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

Treatments most often denied in this category

These are the eosinophilic esophagitis (eoe) treatments most often flagged for prior auth, step therapy, or medical necessity review:

• Dupixent (EoE)
• Eohilia
• Fluticasone (off-label)
• Compounded budesonide
• High-dose PPI
• SFED

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.