Tepezza TED denied as not medically necessary 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 Medical Necessity Denial for Tepezza (Thyroid Eye Disease)

Tepezza (teprotumumab-trbw) is indicated for thyroid eye disease (TED), a progressive autoimmune condition that can cause proptosis, diplopia, corneal exposure, and vision loss. Aetna's medical necessity denials for Tepezza typically arise when the submitted documentation does not clearly establish that the patient's TED has reached the severity or activity level required by Aetna's clinical policy, or when the treating specialty, diagnostic evidence, or prior treatment documentation is incomplete. These denials are highly reversible when the clinical record is comprehensively assembled and mapped to each of Aetna's stated criteria.

## Federal Appeal Rights

• Internal appeal: Under ERISA §503 and ACA §2719, you have the right to a full-and-fair internal appeal. File within the timeframe shown on your denial letter.
• External review: After final internal denial, you may request independent external review — this right is guaranteed under most ACA-compliant plans for approximately four months after the denial becomes final.
• Expedited review: If your ophthalmologist or endocrinologist documents that standard timelines would seriously jeopardize your vision or health, request expedited review for a 72-hour decision.

## What to Include in Your Appeal

1. Clinical activity and severity documentation: Ophthalmology notes documenting proptosis measurements, clinical activity score, diplopia grading, visual acuity, and any corneal involvement — all with dates. This evidence directly addresses severity criteria. 2. Imaging: Orbital MRI or CT scan reports confirming orbital inflammation and/or muscle enlargement consistent with active TED. 3. Endocrinology records: Documentation of underlying thyroid dysfunction or autoimmune status supporting the TED diagnosis. 4. Prior treatment history: Records showing any prior treatment for TED (e.g., corticosteroids, orbital radiation, selenium supplementation) with dates and documented outcomes, to address any step requirements in Aetna's policy. 5. Prescriber medical-necessity letter: A detailed letter from the treating ophthalmologist (ideally an oculoplastic or neuro-ophthalmology specialist) explaining the medical necessity for Tepezza, why the patient's TED has not responded adequately to prior treatment, and why delay risks permanent orbital damage or vision loss. 6. Criteria-mapping table: Reproduce each requirement from Aetna's clinical policy bulletin and answer each with specific chart evidence.

## Criteria-Mapping Structure

| Aetna Medical Necessity Criterion | Your Chart Evidence | |---|---| | TED diagnosis by appropriate specialist | Ophthalmology and endocrinology notes | | Disease activity documentation | Clinical activity score, imaging | | Severity threshold per policy | Proptosis, diplopia, or vision records | | Prior treatment and response | Treatment history with outcomes | | Prescriber specialty requirement | Treating physician credentials |

## Next Step

Obtain Aetna's current clinical policy bulletin for Tepezza directly from aetna.com before filing. Build your criteria-mapping table row by row — this structure signals to the reviewer that the clinical record has been specifically assembled to address each policy requirement, which substantially increases approval rates at the internal level.