Fostamatinib ITP denied for missing prior authorization by Aetna?

Aetna's specific coverage criteria for fostamatinib itp 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 Fostamatinib in ITP

Prior authorization (PA) for fostamatinib is Aetna's standard gate for specialty ITP medications. Aetna uses PA to verify that the patient has a confirmed ITP diagnosis, that the drug is being prescribed within the FDA-approved indication, and that required prior therapy steps have been documented. A PA denial — whether an initial denial or a retrospective denial after emergency use — means the submitted information did not satisfy one or more of Aetna's criteria at the time of review. It is not a final determination of coverage.

## Why This Denial Is Appealable

PA denials are administrative in nature: they reflect what was in the submission, not necessarily what is in the chart. A complete resubmission or formal appeal with the full clinical record almost always resolves what was missing. Under ERISA §503 and ACA §2719, you have the right to know exactly which criterion was not met and to submit additional information addressing it.

## Federal Appeal Framework

• Request the specific deficiency: Before filing a formal appeal, call Aetna and ask which criterion the initial submission failed to satisfy. Many PA denials are resolved at this stage with a supplemental submission.
• Internal appeal: If a formal appeal is needed, file within the deadline on your denial notice. You are entitled to a full-and-fair review under ERISA §503.
• External review: If the internal appeal is denied, file for independent external review within approximately four months. The external reviewer evaluates whether Aetna's criteria are clinically appropriate and whether your documentation meets them.
• Expedited track: Available if the treating hematologist certifies that delay poses a serious risk.

## Documentation to Gather

1. Confirmed ITP diagnosis — hematology records, bone marrow or workup results if performed, and duration of diagnosis. 2. Prior-therapy step documentation — dated records for each ITP treatment previously used, with outcomes and the clinical reason for discontinuation or inadequate response. 3. Current platelet and clinical status — recent labs and provider notes showing current disease activity and why treatment is needed now. 4. Prescriber PA letter — a letter addressing each of Aetna's stated PA criteria point by point, referencing specific chart dates and findings.

## Criteria-Mapping Structure

Obtain Aetna's current PA criteria for fostamatinib (available in their provider portal or by written request). List each criterion and, beside it, the specific chart documentation that satisfies it. Submit this structured table with the appeal to make it easy for the reviewing clinician to confirm compliance.