How to appeal a Highmark inflammatory bowel disease (crohn's + uc) 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 inflammatory bowel disease (crohn's + uc)

Cited policy: BCBS Rinvoq (Upadacitinib) for UC + Crohn's PA

Moderate-severe UC (FDA Mar 2022) or CD (FDA May 2023). Failure or intolerance of >=1 anti-TNF OR contraindication. Induction 45 mg PO daily x 8 wk (UC) or 12 wk (CD), then 15 mg or 30 mg maintenance. TB / HBV / HCV / lipids / CBC screening required. Boxed-warning risk discussion documented.

How Highmark denies inflammatory bowel disease (crohn's + uc) — and how to counter it

Where Highmark pushes back: 1) JAK boxed warning — must fail 2 biologics first; 2) Patient >50 — denied per ORAL-Surveillance; 3) Must try Stelara/Entyvio before JAK.

Counter-arguments that hold up: Rinvoq UC FDA Mar 16, 2022 (U-ACHIEVE + U-ACCOMPLISH Danese Lancet 2022); Rinvoq CD FDA May 18, 2023 (U-EXCEED + U-EXCEL Loftus NEJM 2023). ORAL-Surveillance (Ytterberg NEJM 2022;386:316) was a POST-MARKETING RA cohort >=50 with >=1 CV risk factor — NOT IBD; class boxed warning is patient-specific. AGA UC 2020 + CD 2020 list JAK as parallel option after TNFi failure (or alternative if TNFi contraindicated). Document patient-specific CV / malignancy / VTE risk vs benefit.

What Highmark typically denies for inflammatory bowel disease (crohn's + uc)

Across Highmark's commercial and Medicare books, denials cluster around a small number of patterns. For inflammatory bowel disease (crohn's + uc), expect:

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

Treatments most often denied in this category

These are the inflammatory bowel disease (crohn's + uc) treatments most often flagged for prior auth, step therapy, or medical necessity review:

• Humira (adalimumab)
• Remicade (infliximab)
• Cimzia (CD only)
• Simponi (UC only)
• Stelara (ustekinumab)
• Skyrizi (risankizumab)

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.