How to appeal a Premera Blue Cross cancer treatments 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.

Premera Blue Cross-specific note: BCBS licensee for Washington and Alaska (~2.4M members). Express Scripts PBM. WA OIC oversight. WA has strong mental health parity enforcement and surprise-billing protections that pre-date federal NSA.

What Premera Blue Cross's policy requires for cancer treatments

Cited policy: BCBS Enhertu (Trastuzumab Deruxtecan) for HER2-Low and HER2-Ultra-Low Breast Cancer

HR+/HER2-low (IHC 1+ or IHC 2+/FISH-) or HR+/HER2-ultra-low (IHC 0 with membrane staining per DESTINY-Breast06 criteria) MBC. Prior endocrine therapy + CDK4/6 inhibitor in HR+. ≥1 prior chemotherapy in MBC setting OR rapid recurrence (DESTINY-Breast06 allows treatment-naive MBC if endocrine-resistant). 5.4 mg/kg IV q3wk. Pneumonitis monitoring per FDA REMS. Hematologist-oncologist Rx.

How Premera Blue Cross denies cancer treatments — and how to counter it

Where Premera Blue Cross pushes back: 1) HER2-low not FDA-recognized (outdated); 2) Try Trodelvy or chemotherapy first; 3) HER2 IHC 0 with staining 'too low' for Enhertu; 4) Dose adjustment for prior anthracycline / cumulative cardiotoxicity.

Counter-arguments that hold up: DESTINY-Breast04 (Modi NEJM 2022;387:9) — T-DXd HER2-low MBC: PFS 9.9 vs 5.1 mo, OS 23.4 vs 16.8 mo (HR 0.64). FDA Aug 5, 2022 — HER2-low BC indication. DESTINY-Breast06 (Curigliano Nat Med 2024) — expanded to HER2-ultra-low (IHC 0 with staining); FDA Apr 5, 2024. NCCN Breast v2.2024 Cat 1 for HER2-low MBC post-CDK4/6. Ki-67, prior anthracycline cumulative dose, and ECHO ≥50% per Enhertu REMS — cardiac monitoring required, not contraindication. Trodelvy (Trop-2 ADC) is sequential or subsequent — not a prerequisite per DESTINY-Breast04 design.

What Premera Blue Cross typically denies for cancer treatments

Across Premera Blue Cross's commercial and Medicare books, denials cluster around a small number of patterns. For cancer treatments, expect:

• WA-specific mental health parity violations
• Step therapy via Express Scripts
• Out-of-network reductions
• Specialty drug prior auth

Treatments most often denied in this category

These are the cancer treatments treatments most often flagged for prior auth, step therapy, or medical necessity review:

• Checkpoint inhibitor
• CAR-T
• Targeted oral
• ADC
• Proton therapy
• PET imaging

How to submit the appeal to Premera Blue Cross

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 Premera Blue Cross cited in the denial.
3. File the appeal through Premera Blue Cross's portal (members: https://www.premera.com ; providers: https://www.premera.com/wa/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 WA, 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 Premera Blue Cross's prior-authorization criteria by drug: Premera Blue Cross PA criteria on ApprovalHelp.