See the payer-work structure.

[Practice letterhead]

November 3, 2025

Cigna Specialty Pharmacy — Prior Authorization Department
Fax: [XXX-XXX-XXXX]

Re: Prior Authorization Request — Ustekinumab (Stelara) IV Induction
[Patient Name] · DOB [redacted] · Member ID CIG-XXXX-7781 · Group [XXXXXX]

Dear Reviewer,

I am requesting prior authorization for ustekinumab (Stelara) IV induction therapy for my patient, who carries an established diagnosis of moderate-to-severe Crohn's disease. This request is submitted as an initial authorization and is supported by the clinical record on file.

DIAGNOSIS
- Crohn's disease of the ileum and large intestine, with fistula — ICD-10 K50.813
- Iron-deficiency anemia secondary to chronic GI blood loss — ICD-10 D50.0

REQUESTED SERVICE
- Ustekinumab for IV infusion — HCPCS J3358, weight-based induction dose (~6 mg/kg, single IV induction), followed by 90 mg SC maintenance every 8 weeks
- Administration — CPT 96365

CLINICAL JUSTIFICATION (constrained to record on file)
The patient is a [age]-year-old with biopsy-confirmed Crohn's disease diagnosed [date]. Disease is active and moderate-to-severe: most recent Harvey-Bradshaw Index 11, fecal calprotectin 642 µg/g ([date]), CRP 18 mg/L, and ileocolonoscopy [date] showing deep ulceration in the terminal ileum (SES-CD 14). The patient has lost 6 kg over four months and reports 6–8 loose stools daily with intermittent perianal drainage.

STEP-THERAPY / PRIOR-TREATMENT DOCUMENTATION
Per Cigna coverage policy, the patient meets failure/intolerance criteria across the required prerequisite classes:
1. Corticosteroids — Prednisone taper completed twice; steroid-dependent with flare on taper below 15 mg ([dates]).
2. Immunomodulator — Azathioprine 2 mg/kg × 5 months; discontinued for leukopenia (WBC 2.9) ([date]).
3. Anti-TNF — Adalimumab × 6 months with secondary loss of response (trough <1 µg/mL, anti-drug antibodies positive) ([date]).

COVERAGE-CRITERIA RESPONSE (payer policy)
Cigna Coverage Policy for ustekinumab requires (a) a diagnosis of moderately-to-severely active Crohn's disease, and (b) inadequate response, loss of response, or intolerance to one anti-TNF agent OR a conventional immunomodulator. Both conditions are met and documented above.

GUIDELINE SUPPORT
The American Gastroenterological Association (AGA) Clinical Guideline on the management of moderate-to-severe Crohn's disease recommends ustekinumab for induction and maintenance of remission in patients with prior anti-TNF exposure (conditional recommendation, moderate-certainty evidence).

This therapy is medically necessary to induce remission, prevent stricturing/penetrating complications, and avoid surgical resection. I am available for a peer-to-peer discussion at the number below.

Respectfully,

[Prescriber Name], MD
Gastroenterology · NPI [XXXXXXXXXX]
[Practice phone] · [Practice fax]

Demo example — fictional patient, de-identified for illustration.

[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 the decision period applicable to this request and identified in the current notice or governing plan document
  - 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]

Demo example — fictional patient, de-identified for illustration.

[Practice letterhead]

December 8, 2025

Independent Review Organization (IRO)
c/o UnitedHealthcare Appeals & Grievances
[Address on denial notice]

Re: Request for External / Independent Review
[Patient Name] · DOB [redacted] · Member ID UHC-XXXX-4420
Claim/Appeal Ref: Internal appeal #IA-XXXX-9931 (upheld [date]) · Service: Ustekinumab (J3358)

To the Independent Reviewer,

On behalf of my patient, I am requesting an external (independent) review of UnitedHealthcare's adverse benefit determination. The internal first-level appeal was submitted [date] and upheld [date]; the plan's final internal denial letter advised of the right to external review. The patient has authorized this request and waived applicable confidentiality limits for review purposes.

STATUTORY PATHWAY
This request is made under the external-review process established by the Affordable Care Act §2719 (45 CFR §147.136) and the applicable state external-review framework. For ERISA-governed coverage, this preserves the member's right to an independent medical determination after exhaustion of the plan's internal process. We request a standard external review and reserve the right to request expedited review should the clinical course deteriorate.

WHAT IS UNDER REVIEW
The plan denied ustekinumab as "not medically necessary," asserting the patient had not adequately trialed a second conventional agent. This is factually incorrect on the record (see below) and is the sole basis on which the internal appeal was upheld.

MEDICAL-NECESSITY ARGUMENT FOR THE INDEPENDENT REVIEWER
1. Diagnosis is firm. Biopsy-confirmed moderate-to-severe Crohn's disease (ICD-10 K50.813), objective inflammation (fecal calprotectin 642 µg/g, CRP 18 mg/L, SES-CD 14).
2. Prerequisite trials are complete and documented. Corticosteroid dependence; azathioprine discontinued for leukopenia (WBC 2.9); adalimumab with documented secondary loss of response and positive anti-drug antibodies. The plan's stated rationale overlooks the azathioprine trial recorded in the chart on [date].
3. Guideline-concordant. The AGA guideline endorses ustekinumab after anti-TNF failure; the plan's own coverage policy requires failure of one anti-TNF OR one immunomodulator — the patient has failed both.
4. Harm of delay. Continued active disease risks stricturing/penetrating complications and bowel resection — outcomes far costlier and more harmful than the requested therapy.

I respectfully ask the independent reviewer to overturn the denial and authorize coverage of ustekinumab as medically necessary. The complete record, internal appeal correspondence, and supporting literature are enclosed. I am available for clinician-to-reviewer discussion.

Respectfully,

[Prescriber Name], MD
Gastroenterology · NPI [XXXXXXXXXX]
[Practice phone] · [Practice fax]

Demo example — fictional patient, de-identified for illustration.

PEER-TO-PEER PREP BRIEF — INTERNAL USE ONLY

Patient: [Patient Name] · DOB [redacted] · Member ID ANT-XXXX-3098
Service in dispute: MRI lumbar spine without contrast — CPT 72148
Payer / reviewer: Anthem · Dr. [Medical Director] · Call ref [XXXX]
Denial reason given: "Conservative therapy not documented for required duration."

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CASE SUMMARY (read first — 3 lines)
[Age]-year-old with 7 weeks of progressive low-back pain radiating down the right leg, now with new objective neuro deficit (right foot drop, 4-/5 dorsiflexion) and a positive straight-leg raise. Six weeks of documented conservative care without improvement. Clinical picture concerning for nerve-root compression requiring surgical evaluation.

TALKING POINTS (leverage-ordered — lead with #1)

1. Red-flag neuro deficit overrides the conservative-care clock.
   → Cite chart [date]: "Right foot drop, dorsiflexion 4-/5, diminished right Achilles reflex." New/progressive neurologic deficit is a stand-alone indication for advanced imaging regardless of conservative-therapy duration.

2. Conservative therapy IS documented and adequate.
   → Cite: 6 weeks NSAIDs (naproxen 500 mg BID), 8 sessions physical therapy ([dates]), activity modification — all without improvement. This satisfies the 6-week threshold.

3. Imaging will change management.
   → A positive MRI directs the patient to neurosurgical/spine referral vs. continued non-operative care. This is decision-driving, not confirmatory.

ANTICIPATED OBJECTIONS → REBUTTALS

  • "Only 6 weeks of conservative care."
      You: Policy requires 6 weeks OR a focal neuro deficit. Both are met — see foot drop on [date].
  • "Try epidural steroid injection first."
      You: Injection without imaging is not guideline-supported with a progressive motor deficit; localize the lesion first.
  • "X-ray would suffice."
      You: Plain film cannot evaluate the disc/nerve root; it does not address the surgical question.
  • "Symptoms may resolve."
      You: Motor deficit is worsening over 7 days; delay risks permanent denervation.

THE ONE CLAUSE TO QUOTE
   Anthem/NIA lumbar MRI policy: advanced imaging is indicated where there is "new or progressive neurologic deficit" — independent of conservative-therapy duration. Read it verbatim.

THE ASK
   Approve CPT 72148 (MRI lumbar spine w/o contrast) today on the basis of the progressive motor deficit. If declined, request the specific policy section relied upon and the reviewer's name/credentials for the appeal record.

Demo example — fictional patient, de-identified for illustration.