CGRP mAb Subcutaneous denied for failing step therapy 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 Step Therapy for Subcutaneous CGRP Monoclonal Antibodies — and Why You Can Appeal

Aetna's step-therapy policy for subcutaneous CGRP monoclonal antibodies requires documented evidence that a member has first tried one or more earlier-line preventive migraine treatments. The specific agents and trial durations required are listed in Aetna's current published clinical policy bulletin — those requirements are the controlling source, and they can change with plan year. Step-therapy denials are the single most common initial denial for this drug class, but they are also among the most successfully appealed when prior-treatment history is thoroughly documented.

The most common reason step-therapy appeals fail is incomplete documentation: the treatments were tried, but the chart records are insufficient to prove it. The fix is documentation, not clinical controversy.

## Federal Appeal Framework

Step-therapy denials are subject to 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 the denial, you have approximately four months to request independent external review. Expedited review — with a decision in approximately 72 hours — is available when the standard timeline would seriously jeopardize your health.

Many states have enacted step-therapy override statutes that require an insurer to grant an exception when the required therapy is contraindicated, previously tried and failed, or clinically inappropriate. Confirm whether your state's law applies to your plan type, as this may provide an additional appeal basis.

## Concrete Appeal Steps

1. Obtain Aetna's published clinical policy for CGRP monoclonal antibodies and read the step-therapy requirements in full — list each required agent and the stated trial duration. 2. Work with your prescriber to compile a complete prior-treatment record that addresses every step requirement. 3. For each required agent: if tried, document dates, doses from the chart, duration, and clinical outcome. If not tried, document the clinical reason (contraindication, intolerance, or medical inappropriateness as assessed by the prescriber). 4. Draft a cover letter for the internal appeal that addresses each step-therapy criterion one at a time, referencing the specific document and date that satisfies it.

## Documentation to Gather

• Diagnosis and severity documentation: neurologist or headache-specialist chart notes confirming migraine diagnosis, monthly frequency, functional impact, and whether the condition is episodic or chronic
• Complete prior-treatment history: all preventive agents tried, with start dates, stop dates, doses from the chart, duration, and documented clinical reason for stopping — inadequate response, adverse effect, or medical contraindication
• Prescriber medical-necessity letter: a signed letter that walks through each of Aetna's step-therapy requirements and maps the patient's history to each one, concluding that subcutaneous CGRP therapy is now the medically necessary next step
• Applicable guideline reference: citation to the American Headache Society or American Academy of Neurology guideline supporting escalation to CGRP therapy after failure of earlier-line preventives

## Criteria-Mapping Structure

Build a table: one row per required step in Aetna's policy. Column one is the policy criterion verbatim. Column two is the chart document (note, pharmacy record, or prescriber summary) that proves compliance with that step, with the document date. Column three is the clinical reason if the step was skipped (e.g., documented intolerance or contraindication). This structure makes it impossible for a reviewer to overlook a satisfied criterion and makes any remaining gap explicit and addressable.