How to appeal a Highmark long covid / pasc 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 long covid / pasc

Cited policy: BCBS Compounded Medication Policy — Low-Dose Naltrexone

Compounded medications generally covered when commercially available formulation does not meet clinical need. LDN at 1.5-4.5 mg is sub-therapeutic-for-addiction dose — only available compounded.

How Highmark denies long covid / pasc — and how to counter it

Where Highmark pushes back: 1) Standard naltrexone 50mg available; 2) Compounded medications not covered; 3) LDN experimental for Long COVID.

Counter-arguments that hold up: LDN at 1.5-4.5 mg is MECHANISTICALLY DISTINCT from 50mg (TLR4 antagonism, glial modulation, microglial inhibition) — NOT interchangeable. Bonilla Front Immunol 2023 demonstrated benefit in Long COVID. Compounded form is the ONLY available formulation at therapeutic LDN doses. Request formulary exception per ACA appeal rights. Document failure of standard symptomatic management.

What Highmark typically denies for long covid / pasc

Across Highmark's commercial and Medicare books, denials cluster around a small number of patterns. For long covid / pasc, expect:

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

Treatments most often denied in this category

These are the long covid / pasc treatments most often flagged for prior auth, step therapy, or medical necessity review:

• Multidisciplinary clinic
• Cognitive rehab
• PEM-aware PT / pacing
• Tilt-table / stand test
• POTS pharmacotherapy
• MCAS treatment

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.