Filspari denied for failing step therapy 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 Step Therapy Before Filspari — and How to Overcome It

Aetna's step-therapy requirement for Filspari (sparsentan) means the plan requires documented prior use — and typically documented inadequate response or intolerance — of one or more other agents before it will approve sparsentan for IgA nephropathy (IgAN). This most commonly involves optimized RAAS inhibitor therapy. If you have already been through those prior steps, the appeal is primarily a documentation task. If your prescriber believes step therapy would be clinically harmful or futile, a step-therapy exception is the right path.

Many states have enacted step-therapy override laws requiring insurers to approve exceptions when required prior-step agents are contraindicated, previously failed, or would delay necessary treatment. Verify whether your state's law applies to your plan type.

## Your Federal Appeal Rights

• Internal appeal (ACA §2719 / ERISA §503): Submit your appeal within the deadline on your denial notice. Step-therapy appeals with adequate prior-failure documentation are frequently resolved at the first internal level.
• External review: If internal appeal is denied, escalate to independent external review. The window is typically approximately four months from the original denial.
• Expedited review: If your IgAN is progressing rapidly and delay poses risk of irreversible kidney injury, request expedited review.

## Documentation to Gather

1. Prior-step treatment history — dates, agents tried, doses as recorded in chart, duration, and outcome (inadequate response, intolerance, adverse effect, or other clinical reason for discontinuation). 2. Diagnosis and progression — biopsy-confirmed IgAN, proteinuria trend and kidney function trajectory documented over time in chart, showing the clinical urgency. 3. Step-therapy exception basis — if prior-step agents have not been tried, your prescriber must explain why: prior adverse reaction documented in chart, clinical contraindication per the FDA prescribing label, or documented reason the step would delay necessary treatment. 4. Prescriber medical-necessity letter — specifically addressing each step-therapy criterion in Aetna's published policy, referencing the FDA-approved prescribing label for Filspari and the relevant nephrology guideline organization (e.g., KDIGO) generically. 5. Specialist documentation — a nephrologist's letter carries particular weight in step-therapy appeals for IgAN treatments.

## Criteria-Mapping Structure

Obtain Aetna's step-therapy policy for Filspari from the provider portal. Build a response grid:

| Step-Therapy Requirement | Your Chart Evidence | |---|---| | Required prior agent(s) identified | [List each agent named in Aetna's policy] | | Trial documented or exception basis | [Chart dates / prescriber letter] | | Outcome of prior step | [Response/failure/intolerance documented] | | IgAN diagnosis confirmed | [Biopsy report date] | | Disease progression | [Lab trend dates from chart] |

Answer each row with specific chart facts. The more precisely each step-therapy criterion is addressed in your appeal letter, the less room there is for a second denial on procedural grounds.