Filspari denied for missing prior authorization by Aetna?

Aetna's specific coverage criteria for filspari 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 Filspari — and How to Get It Approved

Prior authorization (PA) for Filspari (sparsentan) is Aetna's standard mechanism for confirming that coverage criteria are met before dispensing this specialty drug for IgA nephropathy (IgAN). A "prior authorization required" denial at the pharmacy typically means the prescription was sent without an active PA on file — not that coverage was reviewed and denied on the merits. The correct first step is submitting the PA request; if the PA is then denied on clinical grounds, that separate denial triggers full appeal rights.

If a PA was already submitted and denied, see the medical-necessity or step-therapy guidance, as applicable.

## Your Federal Appeal Rights (Once a PA Is Denied on the Merits)

• Internal appeal (ACA §2719 / ERISA §503): Any adverse benefit determination — including a PA denial — triggers full-and-fair internal appeal rights. File within the deadline on the denial notice.
• External review: After exhausting internal appeal, you may request independent external review. The window is generally approximately four months from the original denial.
• Expedited review: Urgent or emergent clinical situations qualify for expedited PA and expedited appeal, with decisions required within 72 hours.

## Documentation to Prepare for the PA Submission

1. Diagnosis confirmation — biopsy-confirmed IgA nephropathy with date, current proteinuria and kidney function status as documented in chart. 2. Prior treatment history — any prior RAAS inhibitor or optimized supportive therapy, with dates, duration, and clinical response, as required by Aetna's PA criteria. 3. Clinical severity documentation — chart notes showing current disease activity, progression indicators, and the clinical basis for initiating Filspari now. 4. Prescriber medical-necessity letter — explaining that the request meets each criterion in Aetna's PA policy, with reference to the FDA-approved prescribing label and the relevant nephrology guideline organization (e.g., KDIGO) generically. 5. Specialist attestation — PA approvals for specialty nephrology drugs are strengthened by a nephrologist submitting the request directly.

## PA Criteria-Mapping Structure

Download Aetna's prior authorization criteria for Filspari from the provider portal before submitting. Map each requirement:

| PA Criterion | Supporting Documentation | |---|---| | Biopsy-confirmed IgAN | [Pathology report date] | | Prior therapy documented | [Medication history with dates] | | Disease severity/progression | [Lab trend + chart note dates] | | Nephrologist prescribing | [Specialty + NPI] | | On-label use | [FDA prescribing label] |

Submit all supporting documents with the initial PA request to avoid back-and-forth delays. If the PA is denied, request the specific clinical rationale in writing immediately — that document drives your appeal.