Arni Entresto denied as not medically necessary by Blue Cross Blue Shield?

Blue Cross Blue Shield's specific coverage criteria for arni entresto 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 BCBS Denied Entresto as Not Medically Necessary

Entresto (sacubitril/valsartan) is an ARNI therapy used in heart failure management. A "medical necessity" denial means BCBS's reviewer concluded that the submitted documentation did not demonstrate that the patient's clinical situation met the criteria in BCBS's coverage policy for Entresto. This commonly happens because the chart submitted with the prior authorization was incomplete — it may have lacked objective functional-status data, a clear statement of the heart failure diagnosis subtype, or documentation of prior therapy — rather than because the patient genuinely does not qualify.

## Why This Is Appealable

Medical necessity determinations are based on the clinical record as submitted. If the record was incomplete, the appeal is an opportunity to submit a complete record. If BCBS applied the wrong criteria (for example, using a policy criterion not supported by the FDA label or applicable guidelines), that can be challenged directly. Obtain BCBS's current medical policy for Entresto and map every criterion against the patient's chart.

## Federal Appeal Framework

• Internal appeal (Level 1 and Level 2): File within the deadline on the denial notice. BCBS plans typically offer two internal appeal levels. Use both — each builds the evidentiary record.
• Peer-to-peer review: Before or during the internal appeal, the prescribing cardiologist should request a peer-to-peer conversation with BCBS's medical reviewer. This is often the fastest path to reversal.
• ACA §2719 external review: After exhausting internal appeals, an IRO conducts a de novo clinical review. Window is approximately four months from the final internal denial. Expedited review is available for urgent cardiac cases.
• ERISA §503: Requires BCBS to provide the specific clinical criteria used and all documents relied on in the denial — request these in the appeal letter.

## What to Gather

• Diagnosis confirmation: Echocardiogram or other imaging report confirming the heart failure diagnosis subtype relevant to the FDA-labeled indication.
• Functional status documentation: Recent clinic notes documenting the patient's functional status, symptoms, and clinical trajectory.
• Prior therapy history: Names, start dates, end dates, and documented tolerance or response for each prior heart failure medication — particularly any ACEi or ARB previously tried.
• Prescriber medical-necessity letter: The treating cardiologist's detailed letter tying the patient's clinical picture to each of BCBS's coverage criteria by name, citing the applicable ACC/AHA guideline organization.
• Relevant labs or studies: Any supporting studies (e.g., imaging, functional assessments) that document the severity and trajectory of the patient's condition.

## Criteria-Mapping Structure

Download BCBS's current medical policy for Entresto (sacubitril/valsartan). Create a table with each policy criterion in the left column and the corresponding chart evidence in the right column. The prescriber's letter should explicitly address every criterion — not just the ones that are clearly met, but also any that are borderline, with explanation. Gaps in the table are what reviewers focus on.