CGRP mAb Subcutaneous denied as not medically necessary by Aetna?

Aetna's specific coverage criteria for cgrp mab subcutaneous 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 Denies Subcutaneous CGRP Monoclonal Antibodies for Medical Necessity — and Why You Can Appeal

Aetna's medical-necessity denial for a subcutaneous CGRP monoclonal antibody typically means that the documentation submitted with the prior authorization request did not sufficiently demonstrate that your clinical profile meets the criteria in Aetna's published coverage policy. The most common gaps are: insufficient documentation of migraine frequency and severity, incomplete prior-treatment history, and absence of a prescriber letter that explicitly maps your case to the policy criteria.

This denial is not a permanent door closing — it is a documentation problem, and it is correctable on appeal.

## Federal Appeal Framework

Medical-necessity denials are the core category covered by ACA Section 2719 external review and ERISA Section 503 full-and-fair review. You have approximately 180 days from the denial notice to file an internal appeal. If Aetna upholds its denial, you have up to approximately four months to escalate to independent external review. Expedited review is available when a standard timeline would seriously jeopardize your health or cause severe pain.

## Concrete Appeal Steps

1. Request the specific criteria Aetna applied and identify every criterion your submission did not satisfy. 2. Obtain Aetna's current published clinical policy for CGRP monoclonal antibodies from Aetna's provider portal or member portal. 3. Work with your prescriber to compile documentation that explicitly addresses each unmet criterion. 4. Submit a formal internal appeal with a cover letter that goes criterion-by-criterion through the policy, citing the page and date of each supporting document.

## Documentation to Gather

• Diagnosis and severity documentation: neurologist or headache-specialist chart notes confirming migraine diagnosis, headache frequency per month, functional impact (e.g., missed work days, disability scores from validated tools), and chronicity if applicable
• Prior-treatment history: a complete list of preventive medications tried, with start dates, stop dates, doses from the chart, and documented reason for stopping each (inadequate response, adverse effect, or medical contraindication)
• Prescriber medical-necessity letter: a signed, detailed letter that maps the patient's clinical profile to Aetna's policy criteria point by point and explains why subcutaneous CGRP monoclonal antibody therapy is now medically necessary
• Applicable guideline reference: citation to the American Headache Society or American Academy of Neurology guideline supporting the treatment decision

## Criteria-Mapping Structure

Create a table with one row per criterion in Aetna's policy. In the first column, copy the criterion verbatim. In the second column, enter the document name, date, and specific passage that satisfies it. In the third column, note who can provide supporting testimony if needed. This format — used in the appeal cover letter — forces the reviewer to engage with each criterion individually rather than issuing a blanket uphold.