Fostamatinib ITP denied for failing step therapy 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 Uses Step Therapy for Fostamatinib in ITP

Step therapy (also called "fail-first") is Aetna's requirement that patients try and fail one or more lower-cost or better-studied treatments before the plan will authorize a later-line agent like fostamatinib. For chronic ITP, Aetna's step-therapy protocol typically requires documented use of standard first- and second-line therapies — such as corticosteroids, IVIG, or thrombopoietin receptor agonists — before approving a novel mechanism like a spleen tyrosine kinase (SYK) inhibitor. The denial means Aetna's records do not yet show that those earlier steps were completed.

## Why This Denial Is Appealable

Step-therapy denials are among the most commonly overturned denials in specialty pharmacy. If earlier therapies were tried and failed, never documented in the PA submission, or are contraindicated in your case, the appeal simply requires presenting that evidence. Many states also have step-therapy override laws that require insurers to grant exceptions when prior therapy was tried, failed, would cause harm, or would delay necessary care. Check whether your state's law applies to your plan type.

## Federal Appeal Framework

• Step-therapy exception / internal appeal: Under ERISA §503 and applicable state step-therapy laws, file a formal exception request with documentation of completed steps or clinical contraindication. Aetna must respond within the plan's stated timeframe.
• External review: Available under ACA §2719 after internal exhaustion; approximately four months to file. An independent reviewer will evaluate whether Aetna's step requirements are clinically appropriate for your situation.
• Expedited track: Request if your current platelet count or bleeding history makes delay dangerous; document the urgency in the prescriber's letter.

## Documentation to Gather

1. Complete prior-therapy history — for each required step therapy, provide the drug name, start and stop dates, documented response (platelet counts, bleeding events), and the clinical reason it was discontinued or deemed inadequate. 2. Contraindication or intolerance documentation — if any step drug cannot be used, provide the specific chart note from your hematologist and any supporting records (adverse event documentation, allergy records). 3. Current disease status — recent labs and provider notes showing ongoing disease burden and need for a different mechanism of action. 4. Prescriber step-therapy exception letter — your hematologist should address each of Aetna's required steps, confirm which were completed or are contraindicated, and explain why fostamatinib's distinct mechanism is now medically necessary.

## Criteria-Mapping Structure

Request Aetna's current step-therapy criteria for fostamatinib. Create a table with each required step as a row. For completed steps, enter the date completed and outcome. For steps not completed, enter the clinical reason (failure, contraindication, intolerance) with the corresponding chart reference. Submit this table as an exhibit to your appeal letter.