Tepezza Insurance Denial

Perhaps your doctor has prescribed Tepezza for your thyroid eye disease (TED) or for double vision or eye bulging. After suffering from one or more of these issues, it can be disheartening to receive a Tepezza insurance denial. Insurance companies are supposed to be on your side, helping you when you need help, yet more and more, it can feel as though there is nobody on your side, most of all your insurance company. 

While you pay your insurance premiums and expect that your insurer will hold up its end of the bargain when necessary, this is too often not the case. Receiving a Tepezza insurance denial may have more to do with your insurance company’s financial bottom line than anything else. It can be extremely beneficial to speak to Attorney Scott Glovsky regarding an insurance denial. Scott began his legal career working for law firms that represented large insurance companies. 

He soon realized that he wanted to help people who were suffering because of insurance denials, opening his own law firm in 1999. Since that time, Scott has worked hard to bring justice to those facing insurance denials. His experience working on the other side allows him to understand and counter nearly every tactic used by insurance companies to avoid paying legitimate claims. 

What Is Thyroid Eye Disease?  

Thyroid eye disease is a lifelong, autoimmune condition that affects the eyes and can worsen over time. The body’s immune system can mistakenly attack the tissues behind the eyes in those with thyroid eye disease, leading to inflammation of the fat and muscle tissues behind the eyes. This inflammation can cause red eyes, dry eyes, itchy eyes, bulging eyes, watery eyes, and double vision. 

The less serious symptoms, like red eyes, may eventually go away, but eye bulging and double vision can remain because of the scarring of the tissues. New symptoms may even appear, and existing symptoms can continue to worsen when thyroid eye disease is not properly treated. Some people with thyroid eye disease will also experience pain in, around, and behind the eyes, or pressure behind the eyes, leading to chronic headaches. 

Eyelid retraction, while not a common symptom of thyroid eye disease, affects some people, causing the eyelids to be pulled back, making it difficult to close the eyes, and resulting in the necessity of taping eyelids closed to sleep.  In rare cases, thyroid eye disease can lead to vision loss. 

What is Tepezza?

Tepezza is currently the only drug approved to treat thyroid eye disease by targeting and blocking IGF-1R, thereby preventing muscle and tissue expansion behind the eyes.

Reasons Why Your Tepezza Prescription Could Be Denied?

A Tepezza insurance denial could be from something relatively simple, like an error on the claim form or a lack of necessary supporting evidence. These issues can be corrected, and the claim can be resubmitted. Some insurers may exclude certain prescription drugs or treatments, so you should check your policy to see if this is the case. 

Most insurance companies require “step therapy” when a prescription drug is expensive. This means you must try other, less expensive drugs and show that these drugs do not work for your condition before the insurance company will pay for the more expensive drug. However, no other drug treats thyroid eye disease at its core, only the symptoms, so step therapy is not possible. 

Your insurer may have claimed that the drug is not medically necessary or that it is experimental or investigational. This may mean that the drug is expensive, and your insurance company does not want to pay. A 500 mg injection of Tepezza costs about $16,300, so in many cases, this can bewhy you have received a Tepezza insurance denial. 

What Should You Do if Your Prescription for Tepezza Is Denied?

If you receive a Tepezza insurance denial, do not give up hope. You can file an internal appeal; if that is unsuccessful, you can file an external one. It can be helpful to have your doctor write a letter on your behalf explaining why Tepezza is necessary for your eye condition, how it will help you, and stating that there are no other drugs that will have the same results. An internal appeal asks your insurance company to take a second look at the denial and reconsider. A neutral third party hears an external appeal, and the decision made is binding on your insurance company. 

What Insurance Companies Are More Likely to Issue a Denial for Tepezza?

Tepezza denied by insurance can be frustrating for you when your doctor believes it could significantly help your thyroid eye disease. While any insurer can deny a claim, some are more likely than others to do so. Californians often have one of the following insurers: 

• Anthem Blue Cross
• Blue Shield
• Health Net
• Kaiser
• Cigna
• Aetna
• Medi-Cal Managed Care Plans (Anthem Blue Cross, Promise Health Plan, Health Net, Molina)

How the Law Offices of Scott Glovsky Can Help with Tepezza Denied by Insurance

Attorney Scott Glovsky is the advocate you need at the time you need an advocate most. Tepezza denied by insurance can be a devastating blow when you have suffered the effects of thyroid eye disease for a significant length of time. Scott Glovsky and his legal team have won cases that have impacted millions of insurance policyholders by forcing insurance companies to change their behavior regarding medically necessary treatments. Scott is a trial lawyer – he tries cases, and he wins. Contact the Law Office of Scott Glovsky today.