Acoramidis ATTR Cm denied for missing prior authorization 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 Requires Prior Authorization for Acoramidis in ATTR-CM — and What to Do

Prior authorization (PA) for acoramidis in transthyretin amyloid cardiomyopathy is routine — Aetna requires pre-approval for this drug because it is a high-cost specialty agent for a specific, diagnosis-dependent indication. A "prior-auth-required" denial (sometimes issued when a prescription is submitted without an approved PA on file) is not a judgment that the treatment is inappropriate. It means the administrative step of obtaining approval was not completed before dispensing was attempted.

The path forward is to submit the prior authorization proactively, with complete documentation. If a PA was submitted and denied — rather than simply missing — see the medical-necessity appeal guidance, which addresses the substantive coverage criteria.

## The Prior Authorization Process

1. Your prescribing cardiologist's office initiates the PA. Contact the office and confirm they have submitted or will submit a PA request to Aetna for acoramidis. Most PA submissions go through Aetna's provider portal or by fax; the office should know the process. 2. Aetna reviews against its Clinical Policy Bulletin. Aetna will check whether the submitted clinical information meets its coverage criteria for acoramidis. Obtain a copy of the relevant Clinical Policy Bulletin so you know exactly what the reviewer will check. 3. Timeline: Routine PAs are typically decided within a few business days to two weeks. An urgent/expedited PA (available when delay would harm the patient) must be decided faster — confirm the exact timeframe with Aetna.

## If the PA Is Denied After Submission

You are entitled to appeal. Under ACA §2719 and ERISA §503:

• Internal appeal: File within 180 days of the denial notice.
• External review: Available within approximately four months of a final internal denial, decided by an independent reviewer not affiliated with Aetna.
• Expedited options: Available when the patient's condition is urgent; ATTR-CM is a progressive condition, which may support an expedited request.

## Documentation to Prepare for the PA (and Any Appeal)

1. Confirmed ATTR-CM diagnosis: Imaging, scintigraphy, biopsy, or genetic test results establishing the diagnosis and subtype. 2. Current disease stage and functional status: Recent chart notes documenting symptom burden and any functional decline. 3. Prior-treatment history: Record of prior therapies, their duration, and outcomes. 4. Prescriber medical-necessity letter: A detailed letter from the treating cardiologist addressing each criterion in Aetna's Clinical Policy Bulletin for acoramidis. 5. Applicable guideline support: Reference to the relevant cardiology society guidance supporting treatment of this patient's disease stage and subtype.

## Criteria-Mapping Structure

| Aetna PA Criterion | Supporting Documentation | |---|---| | ATTR-CM diagnosis confirmed | [Imaging/scintigraphy/biopsy result, date] | | Subtype documented | [Genetic test or clinical basis] | | Disease stage meets coverage threshold | [Echo, functional class per chart] | | Specialty prescriber requirement | [Cardiologist/amyloid center note] | | Prior therapies per policy | [Treatment history] |