Tepezza TED denied as duplicate or overlapping therapy by Aetna?

Aetna's specific coverage criteria for tepezza ted 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 May Issue a "Duplicate Therapy" Denial for Tepezza (Thyroid Eye Disease)

Tepezza (teprotumumab-trbw) is an IGF-1R inhibitor specifically developed for thyroid eye disease (TED). An Aetna "duplicate therapy" denial typically occurs when another treatment for TED — most often IV corticosteroids, orbital radiation, or a surgical procedure — is listed on your claim or active authorization file, and the automated review system flags Tepezza as redundant. This denial category is generally appealable because TED treatments differ substantially in their mechanism and clinical purpose, and Tepezza addresses the underlying orbital inflammatory and fibrotic process in a way that other approaches do not.

## Federal Appeal Rights

• Internal appeal: ACA §2719 and ERISA §503 guarantee a full-and-fair internal review. File within the deadline shown on your denial notice (typically 180 days).
• External review: Independent external review is available after final internal denial — under most ACA-compliant plans, for approximately four months from that date.
• Expedited review: If your ophthalmologist or endocrinologist documents that the standard timeline would seriously jeopardize your vision or health, request expedited review (legally required 72-hour response).

## What to Include in Your Appeal

1. Mechanism-differentiation letter from prescriber: Your treating physician should explain in writing how Tepezza's mechanism of action differs from any concurrent or prior TED treatment, and why the other treatment does not address the same clinical endpoint. 2. Clinical documentation of active TED: Notes and imaging (e.g., orbital MRI or CT, clinical activity score) confirming active, moderate-to-severe TED. 3. Prior treatment records: Documentation of any prior or concurrent treatments, their purpose, and their limitations or partial responses. 4. FDA label reference: The FDA-approved label for Tepezza describes its indication; include it to demonstrate that the therapy is not duplicative of other listed treatments. 5. Applicable guideline support: Reference the relevant professional society guidance (e.g., from the American Thyroid Association or European Group on Graves' Orbitopathy) supporting Tepezza's distinct role.

## Criteria-Mapping Structure

| Aetna Criterion | Your Documentation | |---|---| | Distinct indication not covered by concurrent therapy | Prescriber differentiation letter | | Active TED diagnosis | Orbital imaging, clinical notes | | FDA-labeled indication | Label excerpt | | Prescriber specialty confirmation | Treating physician credentials |

## Next Step

Obtain Aetna's published clinical policy bulletin for Tepezza and review each criterion. Call the clinical reviewer line noted on the denial letter to ask specifically which concurrent therapy triggered the duplicate flag — this information will sharpen your appeal argument.