Eohilia denied for missing prior authorization by Aetna?

Aetna's specific coverage criteria for eohilia 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 Eohilia

Eohilia (budesonide oral suspension) is a specialty medication for eosinophilic esophagitis (EoE), and Aetna — like most major insurers — requires prior authorization (PA) before it will cover the drug. A denial labeled "prior authorization required" typically means the prescription was dispensed or submitted before an authorization was obtained, or the PA request was submitted but was denied because the submitted clinical information did not satisfy all of Aetna's coverage criteria.

If you received this denial because a PA was never submitted, the immediate step is for your prescriber to submit the PA request now. If the PA was submitted and denied, this is a formal coverage denial you have the right to appeal.

## Your Federal Appeal Rights

• Internal appeal: Under ERISA §503 and ACA §2719, you have the right to a full internal review of any adverse benefit determination, including a denied PA. Request a written explanation of every criterion the plan applied.
• External review: After exhausting internal appeals, you may seek binding independent external review from an accredited IRO under ACA §2719. The IRO reviews whether the denial is consistent with generally accepted standards of care and the FDA-approved label.
• Expedited review: When your condition is urgent, plans must process expedited PA appeals within 72 hours. Request this in writing if waiting would seriously jeopardize your health.
• Four-month deadline: External review requests are generally due within approximately four months of the final internal denial — confirm the exact deadline on your denial letter.

## The Concrete Appeal Process

1. Obtain the complete PA denial letter detailing every criterion Aetna says was not met. 2. Pull Aetna's published clinical policy for Eohilia — this lists the exact criteria your prescriber must address. 3. Work with your prescriber to compile documentation answering each unmet criterion. 4. Submit a PA reconsideration or formal internal appeal with a complete documentation package. 5. If denied again, file for external review.

## Documentation to Gather

• Diagnosis confirmation: Endoscopy and biopsy reports establishing the EoE diagnosis; specialist notes confirming the diagnosis under the criteria used in current gastroenterological or allergological practice.
• Prior-treatment history: Dated records of all prior EoE-directed therapies (dietary interventions, proton-pump inhibitors, other treatments), including start/stop dates, outcomes, and tolerability.
• Current clinical severity: Office notes documenting symptom burden, any repeat endoscopy results, and any validated patient-reported outcome measures recorded during visits.
• Prescriber medical-necessity letter: A detailed letter from the treating specialist stating the diagnosis, the evidence of prior treatment, why Eohilia is medically necessary at this time, and explicitly addressing each criterion in Aetna's coverage policy.

## Criteria-Mapping Strategy

Request Aetna's exact PA criteria in writing — they are required to provide them. Then create a two-column table: Aetna criterion on the left, specific chart evidence (with dates) on the right. Submit this mapping as an exhibit to the appeal letter. Structured, criterion-by-criterion responses consistently outperform narrative-only appeals because they make the reviewer's job binary: each box is either checked or it is not.