Three sample appeals.

[Practice letterhead]

October 14, 2025

Aetna Medical Affairs
Attn: Pharmacy & Therapeutics Appeals
PO Box 14579
Lexington, KY 40512

Re: [Patient Name] · DOB [redacted] · Member ID AET-XXXX-1234 · Claim # CL-2025-XXXXX
    Appeal of denial dated October 1, 2025 — Skyrizi (risankizumab-rzaa) 150 mg SC

Dear Medical Director,

I am writing on behalf of my patient to formally appeal Aetna's October 1, 2025 denial of Skyrizi for the treatment of moderate-to-severe plaque psoriasis. The denial cites failure of the plan's step-therapy requirement; this is incorrect and inconsistent with both Aetna's own Clinical Policy Bulletin CPB 0658 and current American Academy of Dermatology (AAD) / National Psoriasis Foundation (NPF) 2019 guideline (Menter et al., J Am Acad Dermatol).

CLINICAL HISTORY (constrained to record on file)

The patient has a 4-year history of plaque psoriasis with PASI ≥ 10 documented on the office visit of [date in record]. Topicals (clobetasol propionate 0.05%) were trialed for 12 weeks without meaningful improvement. The patient subsequently completed 16 weeks of methotrexate at 20 mg weekly (titrated from 7.5 mg) with documented LFT monitoring; PASI remained ≥ 10 with active disease across scalp, elbows, and bilateral knees. Methotrexate was discontinued for inadequate efficacy, NOT for tolerability. This satisfies the AAD/NPF criterion for traditional-systemic failure.

POLICY-VERBATIM RESPONSE

Aetna CPB 0658 (Psoriasis: Biologics) specifies coverage for IL-23 inhibitors after "inadequate response to at least one conventional systemic agent (methotrexate, cyclosporine, or acitretin) for ≥ 12 weeks." The patient meets this criterion verbatim. The denial letter's invocation of "preferred TNF-α inhibitor required first" does not appear in CPB 0658 in this clinical context and conflicts with the plan's published criteria.

GUIDELINES SUPPORTING IL-23 OVER TNF-α HERE

Per the AAD/NPF 2019 guideline, IL-23 inhibitors are appropriate first-line biologics in patients with prior conventional-systemic failure; the guideline does NOT require sequential TNF-α failure. The patient has a documented history of latent TB (positive QuantiFERON, completed 9 months of INH) which makes TNF-α biologics relatively contraindicated per AAD/NPF and per the FDA prescribing information for Humira and similar agents.

DEMAND

I respectfully request immediate overturn of the denial and approval of Skyrizi 150 mg SC at the FDA-approved dosing schedule (weeks 0, 4, then every 12 weeks). Per ACA § 2719 (29 CFR 2590.715-2719), I request:

  - Written response within 30 days for this pre-service appeal
  - Peer-to-peer with a board-certified dermatologist if upholding is contemplated
  - Notice of external review rights and the relevant state external-review process

If the denial is upheld, please send the complete Medical Reviewer Statement and identify the reviewer's specialty and license per Aetna's published appeal procedures.

Respectfully,

[Signature]
[Prescriber Name], MD
NPI [XXXXXXXXXX] · DEA [XXXXXXX]
[Practice address]

[Practice letterhead]

October 14, 2025

UnitedHealthcare — Pharmacy Appeals Department
PO Box 30432
Salt Lake City, UT 84130

Re: [Patient Name] · DOB [redacted] · Member ID UHC-XXXX-5678 · Claim # PA-2025-XXXXXX
    Appeal of denial dated September 27, 2025 — Mounjaro (tirzepatide) 5 mg SC weekly

Dear Medical Director,

I am writing to formally appeal UnitedHealthcare's denial of Mounjaro for my patient, who has type 2 diabetes mellitus with concurrent ASCVD risk equivalents. The denial cites "not preferred — must try metformin and an SGLT2 inhibitor first." The patient has done both, with the failures and contraindications documented below.

CLINICAL FACTS (verbatim from record)

  - HbA1c 8.4% on metformin 1000 mg BID + empagliflozin 25 mg daily (12 weeks, dose-titrated)
  - eGFR 47 mL/min/1.73m² — falls below the recommended threshold for continued empagliflozin per the FDA label revision
  - 10-year ASCVD risk 12.4% (ACC/AHA pooled cohort)
  - BMI 34.7 with documented obesity-class metabolic syndrome
  - No history of medullary thyroid cancer, MEN2, or pancreatitis (absent contraindications to GLP-1/GIP receptor agonists)

POLICY ALIGNMENT

UnitedHealthcare's own Clinical Pharmacy Program for GLP-1/GIP receptor agonists (2025 update) covers tirzepatide when:
  - HbA1c remains ≥ 7.0% on dual oral therapy (met), AND
  - The patient has an indication for cardiovascular or renal risk reduction (met — eGFR 47 + ASCVD risk 12.4%)

The denial letter's "step-therapy" rationale does not address the eGFR criterion that medically requires de-escalation of SGLT2 inhibition, nor the ADA Standards of Care 2025 endorsement of tirzepatide as a first-line option in patients with ASCVD or CKD comorbidities (Section 9).

DEMAND

Per ACA § 2719 (29 CFR 2590.715-2719) and ERISA § 502(a)(1)(B), I request:

  - Immediate overturn and approval of Mounjaro 5 mg SC weekly, with on-label titration
  - Written response within 30 days for this pre-service appeal
  - Peer-to-peer with a board-certified endocrinologist or internal-medicine physician
  - Notice of external-review rights under federal and state law

If your plan covers this denial under the Mental Health Parity and Addiction Equity Act (MHPAEA) framework because of comorbid depression/anxiety, please also provide the plan's Non-Quantitative Treatment Limit (NQTL) Comparative Analysis on request.

Respectfully,

[Signature]
[Prescriber Name], MD
NPI [XXXXXXXXXX]
[Practice address]

[Practice letterhead]

October 14, 2025

Anthem Blue Cross Blue Shield — Oncology Medical Policy Appeals
PO Box 27401
Richmond, VA 23230

Re: [Patient Name] · DOB [redacted] · Member ID BCBS-XXXX-9012 · Claim # ONC-2025-XXXXX
    Appeal of denial dated October 3, 2025 — Enhertu (trastuzumab deruxtecan-nxki)

Dear Medical Director,

I am writing to formally appeal Anthem's denial of Enhertu (T-DXd) for my patient with HER2-low metastatic breast cancer, ER-positive, after progression on two prior lines of endocrine therapy. The denial cites "not on Anthem's preferred ADC list." This rationale conflicts with NCCN Clinical Practice Guidelines in Oncology — Breast Cancer Version 5.2025 (Category 1 recommendation) and the DESTINY-Breast04 trial (Modi et al., NEJM 2022; 387:9-20) which directly established the standard of care for this patient's specific tumor profile.

CLINICAL FACTS

  - Pathology: Invasive ductal carcinoma, ER+ (95%), PR+ (60%), HER2 IHC 1+ (HER2-low by DESTINY-Breast04 criteria), Ki-67 22%
  - Stage IV — bone-dominant + 2 hepatic metastases on most recent CT (date in record)
  - Prior lines: (1) Letrozole + ribociclib 10 months → progression; (2) Fulvestrant + alpelisib 6 months → progression
  - ECOG 1, no significant comorbidity precluding HER2-targeted ADC therapy
  - LVEF 60% on most recent echocardiogram

CATEGORY-1 GUIDELINE BASIS

NCCN Breast Cancer Guidelines v5.2025 BINV-Q (Preferred Regimens for ER+/HER2-low, after CDK4/6 + endocrine therapy):
  - "Fam-trastuzumab deruxtecan-nxki (T-DXd) — Category 1"

DESTINY-Breast04 (Modi et al., NEJM 2022) established:
  - Median PFS 9.9 mo (T-DXd) vs 5.1 mo (TPC), HR 0.50 (95% CI 0.40–0.63)
  - Median OS 23.4 mo vs 16.8 mo, HR 0.64 (95% CI 0.48–0.86)
  - HER2-low (IHC 1+ or 2+/ISH–) was the specific population studied

The patient's tumor profile, prior treatment history, and performance status fit the DESTINY-Breast04 criteria precisely. Anthem's denial offers no alternative regimen that is supported by a Category 1 NCCN recommendation for this clinical scenario.

DEMAND

Per ACA § 2719 (29 CFR 2590.715-2719), I request:

  - Immediate overturn and approval of T-DXd at the FDA-approved dose
  - Written response within 30 days; expedited 72-hour review per 29 CFR 2590.715-2719(b)(2)(ii)(B) given metastatic disease and PFS implications of delay
  - Peer-to-peer with a board-certified medical oncologist
  - Notice of external-review rights and the relevant state IRO process

Delay of Category-1 systemic therapy in metastatic disease has direct implications for progression-free and overall survival per the cited evidence. I appreciate your prompt attention.

Respectfully,

[Signature]
[Prescriber Name], MD
NPI [XXXXXXXXXX]
[Practice address]