Acoramidis ATTR Cm denied as not medically necessary by Aetna?

Aetna's specific coverage criteria for acoramidis attr cm are defined in its own published medical/coverage policy and the FDA-approved prescribing label. A successful appeal documents that your medical records satisfy each criterion those sources list — confirmed diagnosis, any required prior treatments (with dates and outcomes), and clinical severity. If the exact criteria weren't included with your denial, request them in writing; your appeal then maps each requirement to the matching fact in your chart.

## Why Aetna Denied Acoramidis for Medical Necessity in ATTR-CM — and How to Appeal

A medical-necessity denial for acoramidis in transthyretin amyloid cardiomyopathy (ATTR-CM) typically means Aetna's reviewer determined that the submitted documentation did not demonstrate the patient meets each criterion in Aetna's clinical policy for the drug. This is rarely a judgment that the drug is inherently inappropriate — it is almost always a documentation gap. The appeal process exists precisely to fill that gap.

ATTR-CM is a progressive, life-limiting disease. Delay in effective therapy can result in clinical deterioration. This urgency is relevant both to the substantive case and to the option of requesting expedited review.

## Why This Denial Is Appealable

Under ERISA §503 and ACA §2719, you are entitled to a full-and-fair internal review by someone not involved in the initial denial, with access to the specific criteria used. If the internal appeal is unsuccessful, an independent external review is available — typically within four months of the final internal denial. External reviewers apply clinical standards independently of Aetna's internal policy thresholds.

## Your Appeal Timeline

• Internal appeal: File within 180 days of the denial notice (verify the exact date on your Explanation of Benefits).
• External review: Request within four months of the final internal denial.
• Expedited internal/external review: Available when the patient's condition is urgent; the progressive nature of ATTR-CM may support this request.

## Documentation to Gather

1. Confirmed ATTR-CM diagnosis: Cardiac imaging results (echocardiogram, cardiac MRI), nuclear scintigraphy findings, biopsy results if performed, and/or genetic testing for hereditary subtype — whichever establishes the diagnosis in the chart. 2. Disease stage and functional status: Chart notes documenting current functional class, symptom burden, and any progression since prior assessments. 3. Prior-treatment history with dates and outcomes: Documentation of any prior therapies and their outcomes, establishing the clinical path leading to the current request. 4. Relevant comorbidities and contraindications to alternatives: Chart documentation of any factors that affect the choice of acoramidis over alternative agents. 5. Prescriber medical-necessity letter: A detailed letter from the treating cardiologist — ideally a heart failure or amyloid specialist — stating why acoramidis is medically necessary for this specific patient, citing the diagnosis, disease stage, and prior treatment course. 6. Applicable guideline reference: Request that the prescriber reference relevant ACC/AHA or amyloidosis society guidance supporting treatment of this patient's disease stage.

## Criteria-Mapping Structure

Request a copy of Aetna's Clinical Policy Bulletin for acoramidis. List each stated coverage criterion, then map it to a specific piece of chart evidence:

| Aetna Coverage Criterion | Chart Evidence Addressing It | |---|---| | ATTR-CM diagnosis confirmed | [Imaging/scintigraphy/biopsy date, result] | | Subtype documented (WT vs. hereditary) | [Genetic test or clinical determination] | | Current functional/disease-stage criteria | [Echo findings, functional class per chart] | | Prior therapy requirements met | [Treatment history log] | | Prescribing specialist type | [Cardiologist / amyloid center note] |

An appeal that maps each criterion to a specific, dated chart fact — rather than a general statement of medical need — is the most effective format.