How to appeal a Highmark thyroid eye disease (ted) — tepezza (teprotumumab) and igf-1r therapy 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 thyroid eye disease (ted) — tepezza (teprotumumab) and igf-1r therapy

Cited policy: Anthem / BCBSA Evidence Positioning System: Teprotumumab for Thyroid Eye Disease

EUGOGO moderate-to-severe TED; CAS-based activity threshold; quantitative proptosis measurement; prior systemic glucocorticoid trial or documented contraindication; euthyroid status; safety baselines (audiogram, glucose / A1c); excludes pregnancy.

How Highmark denies thyroid eye disease (ted) — tepezza (teprotumumab) and igf-1r therapy — and how to counter it

Where Highmark pushes back: 1) Documentation insufficient on CAS / proptosis; 2) Mild TED — selenium recommended first; 3) Steroid trial inadequate; 4) Plan exclusion of specialty biologics.

Counter-arguments that hold up: Submit complete CAS 7-item itemized score and Hertel measurements with base reading. For mild TED selenium is first-line per EUGOGO (Marcocci NEJM 2011) — only escalate to Tepezza for moderate-to-severe. Document failed methylpred or contraindication. For 'plan exclusion' confirm administration under medical (not pharmacy) benefit using HCPCS J3241; reroute. Cite OPTIC + AAO PPP 2022.

What Highmark typically denies for thyroid eye disease (ted) — tepezza (teprotumumab) and igf-1r therapy

Across Highmark's commercial and Medicare books, denials cluster around a small number of patterns. For thyroid eye disease (ted) — tepezza (teprotumumab) and igf-1r therapy, expect:

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

Treatments most often denied in this category

These are the thyroid eye disease (ted) — tepezza (teprotumumab) and igf-1r therapy treatments most often flagged for prior auth, step therapy, or medical necessity review:

• Tepezza standard course
• Tepezza re-treatment
• Tepezza chronic-stable
• IV methylprednisolone
• Oral prednisone
• Orbital radiotherapy

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.