Arni Entresto denied for failing step therapy 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 Applies Step Therapy to Entresto — and Why You Can Appeal

Blue Cross Blue Shield step-therapy (also called "fail-first") denials for Entresto (sacubitril/valsartan) require that a member try one or more lower-cost medications before the plan will cover this drug. In heart failure, step-therapy edits can be clinically inappropriate when a patient has already tried and not tolerated or not responded adequately to the required predecessor agents, or when the treating cardiologist has documented that the step agents are contraindicated for this individual patient.

Many states have enacted step-therapy override laws that require plans to grant an exception when a prescriber documents that the required step is clinically inappropriate. Check whether your state has such a law — it may shorten the override timeline considerably.

## The Federal Appeal Framework

• ACA §2719 External Review: If internal appeal fails, you have the right to independent external review. Check your denial letter for the filing deadline, which is commonly around 180 days but may vary.
• ERISA §503 (employer plans): Requires a full-and-fair review with written explanation citing the specific plan provisions and clinical criteria used.
• Expedited review: Available when the standard timeline would seriously jeopardize health or ability to function. Invoke it in writing at the same time you file your internal appeal.

## What to Gather

1. Step-agent trial history — pharmacy records and chart notes documenting each required prior medication: the dates tried, the doses used (from the chart), and the documented outcome (inadequate response, intolerance, or contraindication). 2. Prescriber's step-therapy override letter — a detailed letter explaining why the required step agents are not clinically appropriate for this patient and why Entresto is medically necessary now. 3. Diagnosis and severity documentation — chart notes, imaging reports, and functional assessments confirming the diagnosis of heart failure and its current severity. 4. Applicable guideline reference — your prescriber may note that the relevant ACC/AHA heart failure guideline recommends Entresto in appropriate patients; cite the guideline organization generically without quoting specific numbers. 5. BCBS's published step-therapy and coverage policy for Entresto — copy each listed step requirement into your appeal and address it directly.

## Criteria-Mapping Structure

For each step the plan requires, document:

| Plan-Required Step Drug | Tried? | Dates | Documented Outcome | |---|---|---|---| | [Drug named in policy] | Yes/No | [From chart] | [Inadequate response / intolerance / contraindicated per prescriber] |

If any step was not tried because it was clinically inappropriate, include your prescriber's written explanation of why.

## Next Steps

Submit your internal appeal with a complete documentation package. Request a peer-to-peer review between your cardiologist and the plan's medical director — this is a standard right and often resolves step-therapy denials without external review. If internal appeal is denied, file for external review immediately.