Tepezza TED denied for failing step 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 Requires Step Therapy for Tepezza — and How to Override It

Tepezza (teprotumumab) treats active thyroid eye disease (TED). Even though it is the only FDA-approved therapy specifically indicated for TED, Aetna may require documentation that certain prior treatments were tried and failed before it will authorize Tepezza. This is called step therapy — sometimes informally called "fail first."

### Why This Denial Happens

Step-therapy protocols are built into Aetna's utilization-management system. The plan's coverage policy specifies which prior treatments must be attempted, at what level of effort, and with what documented outcomes before a higher-cost or specialty agent is approved. When a Tepezza request arrives without that documentation, the system generates an automatic denial.

### Why It's Appealable — Including Step-Therapy Override

Many states have enacted step-therapy override laws that require insurers to grant an exception when prior therapy would be clinically inappropriate, contraindicated for the specific patient, or unlikely to be effective based on the patient's history. Even in states without such a law, the ACA §2719 external-review right and ERISA §503 full-and-fair review right apply. You have approximately four months from the denial notice to request external review, and an expedited pathway is available for urgent cases.

### Concrete Appeal Process

1. Request the full policy — Ask Aetna in writing for the specific step-therapy criteria being applied to Tepezza for TED. 2. Step-therapy override request — File a clinical exception request simultaneously with your internal appeal, citing your state's override law (if applicable) and the clinical rationale for bypassing required steps. 3. Internal appeal — Submit within the deadline on your denial letter with the full documentation package below. 4. External review — Available after an adverse internal decision; request through your state insurance commissioner or the federal process.

### Documentation to Gather

• Diagnosis confirmation — specialist chart notes, orbital imaging, and objective disease-activity scoring documented by the treating ophthalmologist or endocrinologist.
• Prior-treatment history — records for every treatment Aetna's policy lists as required steps, including start and end dates, doses used, duration, and the reason for discontinuation or documented inadequate response.
• Clinical severity documentation — current disease-activity status from the chart, noting any proptosis measurements, diplopia scores, or visual acuity findings your provider recorded.
• Medical-necessity letter — your prescriber should explain why each required prior step is clinically inadequate, contraindicated, or was already attempted and failed, and why Tepezza is now the appropriate choice per the applicable professional society guideline.

### Criteria-Mapping Structure

Obtain Aetna's Tepezza coverage policy and list every step-therapy requirement in a table. Opposite each requirement, insert the chart fact that satisfies or addresses it — including date, source document, and outcome. If a required step was never attempted because it was clinically inappropriate, document that reason with a prescriber statement. A complete criteria map is your strongest tool: it forces the reviewing clinician to address each point individually rather than issue a blanket denial.