Tepezza TED denied for missing prior authorization 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 Requires Prior Authorization for Tepezza (Thyroid Eye Disease)

Tepezza (teprotumumab-trbw) is a specialty biologic administered as an intravenous infusion series for thyroid eye disease (TED). Aetna, like most commercial insurers, requires prior authorization before Tepezza is administered because it is a high-cost specialty therapy with specific clinical eligibility criteria. A "prior authorization required" denial means either that PA was not obtained before infusion, or that the PA request was submitted with incomplete documentation and was not approved before the claim was filed. This is among the most actionable denial types: a properly documented retrospective appeal — or a new PA submission — can typically resolve it.

## Federal Appeal Rights

• Internal appeal: ERISA §503 and ACA §2719 guarantee a full-and-fair internal review of any adverse benefit determination. File within the deadline on your denial notice.
• External review: After final internal denial, you may request independent external review — available under most ACA-compliant plans for approximately four months after the final denial date.
• Expedited review: If your ophthalmologist or endocrinologist certifies that delay would seriously jeopardize your vision or health (TED can cause permanent proptosis and vision loss without treatment), request expedited review for a legally required 72-hour response.

## What to Include in Your Appeal

1. Complete PA documentation package (retrospective): Submit the full clinical documentation that should have accompanied the original PA request, including the diagnosis, specialty confirmation, disease activity, prior treatment history, and prescriber letter. 2. Diagnosis documentation: Ophthalmology notes with clinical activity score, proptosis measurements, diplopia grading, orbital imaging (MRI or CT), and endocrinology records confirming thyroid autoimmunity. 3. Prescriber medical-necessity letter: Your treating ophthalmologist should explain the urgency of treatment, the natural history of untreated active TED, and why Tepezza was medically necessary at the time of administration. 4. Prior treatment history: Records documenting any prior treatment for TED and the response, to demonstrate that the prescribing sequence is consistent with Aetna's coverage criteria. 5. Criteria-mapping table: Reproduce each Aetna PA criterion for Tepezza and address each with specific documentation.

## Criteria-Mapping Structure

| Aetna PA Criterion | Your Documentation | |---|---| | TED diagnosis confirmed by appropriate specialist | Ophthalmology and endocrinology notes | | Disease activity documentation | Clinical activity score, imaging | | Severity requirement per Aetna policy | Proptosis, diplopia, visual acuity records | | Prior treatment history per policy | Treatment records with dates | | Prescriber specialty | Treating physician credentials |

## Next Step

Download Aetna's current PA criteria for Tepezza from aetna.com before filing. The treating infusion center's patient services coordinator frequently manages these appeals and may have a pre-built documentation template that maps to Aetna's specific requirements — ask before assembling your package from scratch.