Crenessity CAH denied for failing step therapy by Blue Cross Blue Shield?

Blue Cross Blue Shield's specific coverage criteria for crenessity cah 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 Crenessity for CAH — and Why You Can Appeal

Blue Cross Blue Shield's step-therapy requirement for Crenessity (tildacerfont) typically means the plan requires evidence that the patient has first tried one or more other treatments for congenital adrenal hyperplasia before it will authorize coverage of Crenessity. In practice, this usually means documented use of conventional glucocorticoid therapy. The denial does not mean Crenessity is inappropriate — it means the plan requires proof that prior steps were taken, or a clinical explanation of why they were not.

For many patients with CAH who have already been on glucocorticoid therapy for years, the required prior step has already been taken — and the appeal simply requires submitting the documentation that proves it. For patients where the step is not appropriate, the prescriber can request a step-therapy exception.

## Federal Appeal Rights

• ACA §2719 external review: After exhausting internal appeals, you may request independent external review within approximately four months of the final denial notice — confirm your exact deadline on the denial letter. Expedited review is available for urgent cases.
• ERISA §503: Employer-plan members are entitled to a full-and-fair review that explains precisely which step was required and why the submitted documentation was found insufficient.
• State step-therapy exception laws: A growing number of states require insurers to grant exceptions to step-therapy requirements when the required therapy was already tried, is contraindicated, or when the prescribed drug is standard of care. Verify whether your state's law applies to your plan type (state law typically does not apply to self-funded ERISA plans).

## Concrete Appeal Steps

1. Obtain BCBS's step-therapy policy for Crenessity in CAH. Identify each required prior step — medication name, and any criteria around duration or outcome. 2. Document prior therapy with dates and outcomes. For each required step, provide the medication name (from the chart), start and stop dates, prescribing physician, and the chart-documented clinical response. If the patient is still on glucocorticoid therapy (as would be expected with an adjunctive agent), document this explicitly. 3. If a required step was never taken: Obtain your prescriber's letter explaining why — for example, that the patient has an allergy, documented intolerance, or that the therapy is clinically inappropriate for this patient — and request a step-therapy exception. 4. Obtain the prescriber's medical-necessity letter summarizing the full treatment history and linking it to each BCBS step-therapy criterion. 5. File the internal appeal within the plan's stated deadline with a criteria-mapping cover sheet.

## Criteria-Mapping Structure

| BCBS Step-Therapy Requirement | Your Documentation | |---|---| | Prior glucocorticoid therapy (or other required step) | Chart records with medication name, dates, prescriber, and documented response | | Inadequate response or exception basis | Prescriber letter citing chart-documented clinical outcome or exception ground | | Confirmed CAH diagnosis | Diagnostic records and endocrinology notes | | Prescriber attestation | Medical-necessity letter addressing each step-therapy criterion |

Review BCBS's current step-therapy policy for Crenessity before submitting — the required steps and exception criteria are defined there, and your documentation package must address each one explicitly.