Soliris MG denied as not medically necessary by Aetna?

Aetna's specific coverage criteria for soliris mg 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 Soliris (Eculizumab) for Medical Necessity

A medical-necessity denial from Aetna means the plan's reviewer determined that Soliris (eculizumab) was not proven to be necessary, appropriate, and consistent with accepted standards of medical practice for your specific clinical situation. For Soliris — a complement-inhibitor used in serious rare diseases — this denial most often results from insufficient clinical documentation in the submitted record, a mismatch between the documented severity of disease and the plan's coverage threshold, or an incomplete prior-authorization package that failed to address each of the insurer's criteria.

Because the underlying conditions treated by Soliris can be life-threatening, this denial is both legally and clinically contestable.

## Federal Appeal Framework

• Internal appeal (ERISA §503 / ACA §2719): Plans must provide a full-and-fair internal review. You generally have 180 days from the denial notice to file.
• External review (ACA §2719): If the internal appeal fails, you are entitled to independent external review. The request window is approximately four months from final internal denial. Expedited review is available if your condition is urgent or if delay would seriously jeopardize your health.

## Appeal Process and Timeline

1. Request the complete denial letter, the specific coverage criteria used, and the name and specialty of the reviewing clinician. 2. Have your treating specialist review Aetna's criteria and prepare a point-by-point rebuttal letter. 3. Submit the internal appeal with all supporting documentation simultaneously. 4. If denied, file for external review promptly — request expedited if the clinical situation warrants.

## Documentation to Gather

• Diagnosis confirmation: Specialist-authored records, laboratory findings, imaging, and pathology that firmly establish the diagnosis and its severity, using terminology that matches the plan's coverage criteria.
• Clinical severity documentation: Chart notes, functional assessments, and objective markers (lab trends, imaging results) demonstrating the degree of illness and the urgency of treatment.
• Prior-treatment history: A chronological list of all prior treatments for this condition with start/stop dates, doses (obtained from your pharmacy record or chart), and documented outcomes — including why each was discontinued or deemed inadequate.
• Prescriber medical-necessity letter: A detailed letter from the treating specialist explaining the pathophysiology, the clinical necessity of complement inhibition, and why Soliris is the appropriate agent, referencing the applicable specialist society guidelines by organization name.

## Criteria-Mapping Structure

Obtain Aetna's clinical policy bulletin for Soliris. List every coverage criterion in a table. For each criterion, provide the exact corresponding fact from the medical record — the chart date, the lab value, the specialist note. Do not leave any criterion unanswered. Confirm that all dosing, eligibility thresholds, and specific clinical requirements align with what the FDA-approved prescribing label and Aetna's own policy specify; do not rely on third-party summaries for these numbers.