Daa Pangenotypic Mavyret denied for missing prior authorization by Aetna?

Aetna's specific coverage criteria for daa pangenotypic mavyret 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 Mavyret

Aetna applies prior-authorization (PA) requirements to most specialty drugs, including pangenotypic direct-acting antivirals like Mavyret (glecaprevir/pibrentasvir). A denial coded as "prior authorization required" means either that no PA was submitted before the prescription was filled, or that a submitted PA was incomplete and was rejected before clinical review began. This is a process barrier — not a clinical judgment — and it is resolved by completing the correct administrative steps.

## Why This Denial Is Appealable

If the PA was submitted and improperly rejected, or if retrospective authorization is available under your plan, this denial is directly appealable. Even if no PA was filed, a prescriber-initiated PA request submitted now — with a complete clinical package — will typically resolve the coverage question within Aetna's standard review window.

## Federal Appeal Framework

• ACA §2719 / ERISA §503: Plans must provide a full-and-fair review process, including for PA denials.
• Timeline: Internal appeal must generally be filed within 180 days of the denial notice. If internal review is denied, external review is available within approximately 4 months of that decision.
• Expedited option: Expedited PA and expedited appeal (within 72 hours) are available when standard timelines would seriously jeopardize health.

## The Appeal Process

1. Confirm with your prescriber's office whether a PA was filed and, if so, obtain the PA tracking number and any rejection notice. 2. If no PA was filed, submit one immediately using Aetna's current PA request form for Hepatitis C DAAs, with a complete clinical package. 3. If a PA was filed and denied, file the internal appeal with the denial letter, the complete clinical package, and a prescriber letter addressing each of Aetna's published PA criteria. 4. Request a peer-to-peer review between your prescriber and Aetna's medical director — this is your prescriber's right and frequently resolves PA denials without formal appeal. 5. If internal appeal is denied, escalate to external review.

## Documentation to Gather

• Active HCV diagnosis: Genotype result and viral load confirming current infection.
• Disease staging: Fibrosis or cirrhosis documentation from the medical record.
• Treatment history: Dates and outcomes of any prior HCV therapy, or documentation of treatment-naive status.
• Prescriber letter: Addresses each criterion in Aetna's current PA policy for HCV DAAs, citing specific chart dates and results.
• PA submission records: Copies of any prior PA submissions and any rejection or denial notices from Aetna.

## Criteria-Mapping Structure

Obtain Aetna's published PA criteria for Hepatitis C DAA coverage and the FDA-approved Mavyret prescribing label. Build a two-column table: left column lists each PA criterion; right column cites the exact chart fact, date, and document satisfying it. A complete, criterion-by-criterion match is the most efficient path through the PA process.