Arni Entresto denied for missing prior authorization 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 Requires Prior Authorization for Entresto

Entresto (sacubitril/valsartan) is subject to prior authorization (PA) by most BCBS plans because it is a specialty-tier heart failure therapy with a higher cost than generic alternatives in the same class. BCBS's PA program is designed to verify that the patient has a confirmed diagnosis within the FDA-labeled indication, that relevant clinical criteria are met, and — in many plans — that certain prior therapies have been tried. A "prior-auth-required" denial means the service was rendered without a completed authorization, or a PA was submitted but lacked sufficient documentation.

## Why This Is Appealable

If the PA was denied for lack of documentation, the appeal is an opportunity to provide a complete clinical record. If care was rendered without PA due to urgency, a retrospective authorization request may be available. In either case, the appeal should systematically address every criterion in BCBS's PA policy for Entresto — criteria that are available in the published medical policy, which you can request from BCBS's provider services or member services line.

## Federal Appeal Framework

• Internal appeal (Level 1 and Level 2): File within the deadline on the denial letter. Request the specific clinical criteria used in the denial under ERISA §503 if the plan is employer-sponsored.
• Peer-to-peer review: The prescribing cardiologist should proactively request a peer-to-peer with BCBS's medical director before the internal appeal deadline — this is frequently the most efficient path to resolution.
• ACA §2719 external review: Available after exhausting internal appeals. Window is approximately four months from the final internal denial. An IRO will evaluate whether the PA denial was clinically appropriate.
• Expedited review: Available when the patient's cardiac condition is unstable or deteriorating and delay in therapy poses a risk of serious harm.
• ERISA §503: Requires BCBS to provide all criteria, evidence, and clinical guidelines relied upon in the denial decision.

## What to Gather

• Diagnosis documentation: Echocardiogram or other objective study confirming the heart failure subtype and functional status relevant to the FDA-labeled indication.
• Prior ACEi/ARB history: Documentation of any prior therapy in the same class — drug name per prescriber records, dates, and reason for discontinuation or transition (tolerability, inadequate response, or planned transition to ARNI per guidelines).
• Current medication list: Confirming the full heart failure regimen and demonstrating guideline-directed medical therapy.
• Prescriber medical-necessity letter: A detailed letter from the treating cardiologist addressing each of BCBS's PA criteria by name, referencing the applicable ACC/AHA guideline organization's recommendation and tying it to this specific patient's clinical situation.
• Relevant functional and imaging studies: Supporting the severity and trajectory of the patient's condition.

## Criteria-Mapping Structure

Obtain BCBS's PA criteria for Entresto from the published medical policy. In the appeal letter, list each criterion verbatim and provide the corresponding chart fact. The prescriber letter should mirror this structure so the reviewer can verify each criterion without hunting through the record.