CGRP mAb Subcutaneous denied for missing prior authorization 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 Requires Prior Authorization for Subcutaneous CGRP Monoclonal Antibodies — and What to Do

A prior-authorization-required denial is procedural, not clinical. Aetna has determined that subcutaneous CGRP monoclonal antibodies require advance approval before the pharmacy will dispense them, and either that authorization was not obtained, or the authorization was denied after review. Understanding which scenario you are in determines your next step.

If authorization was never requested, the path forward is to submit a prior authorization through your prescriber's office using Aetna's standard PA process. If authorization was requested and denied, you are in an appeal situation and the denial reason that accompanied the PA denial — not the phrase "prior auth required" — is the criterion you need to address.

## Federal Appeal Framework

If a prior authorization was submitted and denied, that denial is an adverse benefit determination subject to ACA Section 2719 external review and ERISA Section 503 full-and-fair review. File an internal appeal within approximately 180 days of the denial notice. Expedited review is available if the standard timeline would seriously jeopardize your health — Aetna must decide an expedited PA within 72 hours. If the internal appeal is upheld, you have approximately four months to request independent external review.

## Concrete Appeal Steps

1. Confirm with your prescriber's office whether a prior authorization was ever submitted, and if so, whether a denial was received. 2. If no PA was submitted, have your prescriber submit one through Aetna's standard channel (typically via Emdeon/Change Healthcare or Aetna's provider portal). 3. If a PA was submitted and denied, obtain the denial notice and identify the specific clinical criteria cited as unmet — those criteria, not the "PA required" label, are what your appeal must address. 4. Pull Aetna's published clinical policy for CGRP monoclonal antibodies to understand all authorization criteria before submitting documentation.

## Documentation to Gather

• Complete PA submission records: including the submitted diagnosis code, requested drug and quantity, and any clinical notes submitted with the original request
• Diagnosis documentation: chart notes confirming migraine diagnosis, frequency, and severity from a neurologist or headache specialist
• Prior-treatment history: documentation of prior preventive therapies tried, with dates, doses from the chart, duration, and clinical outcome
• Prescriber medical-necessity letter: a signed letter addressing each of Aetna's published PA criteria for this drug

## Criteria-Mapping Structure

Aetna's PA criteria are published in its clinical policy bulletins. Before re-submitting or appealing, obtain the current version of that policy and list every criterion. For each criterion, identify which document in your chart satisfies it. Ensure that the prescriber's medical-necessity letter explicitly addresses each criterion using the same language Aetna uses in its policy. A PA submission or appeal that maps directly to the policy criteria is significantly more likely to be approved.