Dupixent Asthma denied for missing prior authorization by Aetna?

Aetna's specific coverage criteria for dupixent asthma 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 Dupixent for Asthma — and What to Do If It Is Denied

Prior authorization (PA) denials for dupilumab (Dupixent) in asthma from Aetna occur in two scenarios: (1) a PA was never submitted before the prescription was filled or administered, resulting in a retrospective denial; or (2) a PA was submitted but denied because the documentation did not satisfy Aetna's clinical criteria. Both scenarios are addressable through the appeal process.

### Why This Denial Is Appealable

Prior authorization requirements must be applied in a clinically reasonable way. If your PA was denied on clinical grounds, Aetna must specify which criteria were not met — and you have the right under ERISA §503 and ACA §2719 to a full-and-fair internal appeal followed by independent external review. If the PA was denied for an administrative reason (e.g., not submitted in time), appeal rights may be more limited but still exist in many cases, particularly when a delay would cause harm. Expedited review is available when your health is seriously at risk.

### Your Appeal Timeline

• Internal appeal: File within the deadline on your denial notice (commonly 180 days for ERISA plans). Standard decisions within 30–60 days; expedited within 72 hours for urgent/concurrent review situations.
• External review: After internal denial, approximately four months to request independent external review. Expedited external review available for urgent situations.

### Documentation to Gather

1. Diagnosis confirmation — pulmonary function tests, specialist notes, and chart documentation establishing the diagnosis and severity of asthma consistent with the FDA-approved indication. 2. Phenotype documentation — laboratory and clinical records supporting the qualifying inflammatory profile described in the FDA label. 3. Prior controller therapy history — a comprehensive, dated record of add-on controller medications tried, consistent with the add-on maintenance framework in the FDA label. 4. Clinical severity documentation — exacerbation frequency, oral corticosteroid burden, emergency or hospital visits, and validated symptom scores. 5. Prescriber medical-necessity letter — your allergist or pulmonologist should map your case to each criterion in Aetna's PA requirements, citing the FDA-approved indication and the applicable professional society guideline organization (e.g., GINA or NAEPP framework).

### Criteria-Mapping Structure

Aetna is required to provide you with the specific PA criteria it applied. Build your appeal around a point-by-point response:

| PA Criterion (from Aetna's policy) | Your Chart Evidence | |---|---| | Confirmed moderate-to-severe asthma | [PFT date, specialist note] | | Qualifying phenotype per FDA label | [Lab or clinical documentation] | | Required prior controller therapies | [Each therapy, date, outcome] | | Prescribing specialist | [Physician specialty and credentials] |

If the PA was administratively denied, include a letter from your prescriber explaining why the authorization was not obtained in advance (e.g., urgent clinical need) and why retrospective approval is warranted. Attach the current FDA-approved prescribing information for dupilumab as a primary-source exhibit.