Tepezza TED denied due to quantity / dose limits 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 Limits Tepezza Quantities — and Why You Can Appeal

Tepezza (teprotumumab) is an FDA-approved infusion therapy for thyroid eye disease (TED). Aetna, like most commercial payers, applies quantity or supply limits to Tepezza coverage — typically restricting the number of infusions approved in a single authorization period. A quantity-limit denial means the plan is willing to cover the drug but will not approve beyond a defined count without additional justification.

### Why This Denial Happens

Payers set quantity limits based on the labeled treatment course described in the FDA-approved prescribing information. When a prescriber requests a number of infusions that differs from or extends beyond what the initial authorization covers, the claim may be pended or denied automatically by utilization-management software — even when the patient's clinical situation clearly warrants it.

### Why It's Appealable

Quantity limits are not absolute. Federal law protects your right to challenge them. Under the ACA (§2719) and, for employer-sponsored plans, ERISA (§503), every member must have access to a full-and-fair internal review followed by an independent external review. External review requests must generally be filed within approximately four months of receiving a denial notice — check your Explanation of Benefits for the exact deadline. An expedited review (decision within 72 hours) is available when your prescriber documents that waiting for the standard timeline would seriously jeopardize your health.

### Concrete Appeal Process

1. Internal appeal — Submit a written appeal to Aetna within the timeframe shown on your denial letter (commonly 180 days). Request the specific clinical criteria and quantity-limit policy Aetna applied. 2. External review — If the internal appeal is denied, request independent external review through your state's insurance commissioner or through the federal external-review process. 3. Expedited track — Ask your ophthalmologist or endocrinologist to certify urgency if continued disease activity creates an imminent risk.

### Documentation to Gather

• Diagnosis confirmation — chart notes, imaging (orbital MRI or CT), and clinical activity score documented by the treating specialist.
• Prior infusion history — dates of all infusions already received, clinical response notes after each infusion, and any residual or active disease findings.
• Medical-necessity letter — a detailed letter from your prescriber explaining why the requested quantity is necessary, referencing the disease course and the applicable professional society guideline (such as guidance from the American Thyroid Association or the relevant ophthalmology society).
• FDA label reference — confirm the requested quantity aligns with the labeled treatment course; obtain this directly from the current FDA-approved prescribing information.

### Criteria-Mapping Structure

Print Aetna's published medical/coverage policy for Tepezza and the FDA prescribing label side-by-side. For each requirement listed — diagnosis, disease activity, treatment history, quantity rationale — write the matching fact from your chart with the date and source document. Gaps in documentation are the most common reason quantity appeals fail; a complete one-to-one mapping gives the reviewing physician a clear path to approval.