Evenity denied for missing prior authorization by Aetna?

Aetna's specific coverage criteria for evenity 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 Denied Evenity for Missing Prior Authorization

Evenity (romosozumab) is a high-cost specialty biologic, and Aetna requires prior authorization before it will cover the drug in virtually all commercial and Medicare Advantage plans. A prior-auth-required denial means the prescription was dispensed or administered before Aetna issued an approval, or that the authorization request was submitted but did not include sufficient documentation for Aetna to approve it under its clinical policy criteria. This is one of the most common denial types for specialty osteoporosis therapies and is frequently reversible on appeal.

## Why This Denial Is Appealable

If the prior authorization was never requested, the appeal is an opportunity to retroactively supply the clinical documentation and request a retrospective review. If it was requested and denied, this is a standard medical-necessity appeal. If the authorization was granted but something administrative went wrong (wrong date, wrong quantity, wrong setting of care), that administrative error is correctable. You are entitled to a full internal appeal under ERISA §503 or your state's insurance law, and to independent external review under ACA §2719 after internal remedies are exhausted, generally within approximately four months of the final internal denial. Expedited review is available when your physician certifies that a standard review timeline would jeopardize your health.

## Your Appeal Timeline

1. Determine from your prescriber's office whether a prior authorization was ever submitted and what its status is. 2. Request the denial letter and Aetna's clinical policy for Evenity to understand the coverage criteria. 3. File a first-level internal appeal within the deadline shown on your Explanation of Benefits, including all clinical documentation. 4. Escalate to external review if internally denied.

## Documentation to Gather

• Authorization records: Any prior authorization request number, submission date, or reference number from your prescriber's office or specialty pharmacy.
• Diagnosis confirmation: DXA scan reports with T-scores, fragility fracture history with radiology reports, and fracture risk assessment.
• Prior osteoporosis treatment history with outcomes: A chronological record of every prior osteoporosis medication — with start dates, stop dates, and documented reasons for stopping (inadequate efficacy, adverse effect, intolerance) — supported by pharmacy records and chart notes.
• Clinical severity: Physician notes documenting cumulative fracture burden, ongoing fracture risk, and functional status.
• Prescriber medical-necessity letter: A detailed letter from your prescribing endocrinologist or specialist addressing each criterion in Aetna's clinical policy for Evenity, confirming the diagnosis, the prior-therapy history, and the clinical rationale for choosing romosozumab.

## Criteria-Mapping Structure

Obtain Aetna's prior authorization clinical criteria for Evenity. Then provide evidence for each:

| Aetna Prior Auth Criterion | Your Chart Evidence | |---|---| | Diagnosis of severe osteoporosis or high fracture risk | Cite DXA report and fracture history | | Prior therapy requirement met | Cite medication history with dates and outcomes | | Prescribed by qualified specialist | Cite prescriber specialty and NPI | | No concurrent anabolic therapy | Cite current medication list |

A complete, criterion-by-criterion submission that addresses every item in Aetna's clinical policy — including the prior-therapy step requirements — gives the reviewer everything needed to approve the authorization on appeal.