Florida Blue appeal: Step therapy requirement not met.

The appeal letter (copy and edit)

Copy the body below and paste it into your clinician's portal or word processor. Replace every [BRACKET] placeholder with patient-specific data. Attach the original denial letter, the original PA submission, and any new documentation that directly addresses the denial reason. The letter is from your clinician to the plan, signed by your clinician.

[Today's date]

Florida Blue
Prior Authorization Appeals Department
Submitted via: Availity provider portal or fax 1-877-265-5839

Re: APPEAL of prior authorization denial
Patient: [Patient full name]
Member ID: [Plan member ID]
Date of birth: [Patient DOB]
Original PA reference number: [Reference number from denial letter]
Date of denial: [Denial letter date]
Date of this appeal: [Today]

To the Florida Blue Appeals Review Department,

I am the treating clinician for [Patient name]. I am writing to formally appeal the denial dated [denial date] of my prior authorization request for [drug name] in the indication of [indication name].

The denial reason cited

The denial cites: "Step therapy requirement not met". The plan's specific stated rationale was: [quote exact language from the denial letter].

This appeal directly addresses that specific reason.

Clinical context

[Insert 2-3 sentences summarizing the patient's clinical picture: BMI, age, comorbidities, prior treatment history and why this medication was prescribed.]

Direct rebuttal to the denial reason

The denial cites failure to meet step-therapy criteria. The patient has documented [prior phentermine trial with intolerance / contraindication to phentermine due to (specific cardiovascular condition with ICD-10) / contraindication to orlistat due to (specific GI condition with ICD-10)]. Per the plan's own PA criteria document, prior trial or documented contraindication satisfies the step-therapy requirement. The relevant documentation is attached.

Patient-specific supporting findings

  - [Current weight, height, BMI with date measured]
  - [Comorbidity ICD-10 codes and the date each was documented]
  - [Prior treatment trials with dates and outcomes]
  - [Any lifestyle intervention documentation]
  - [Any specialty consultation supporting the requested treatment]

Supporting evidence

  - American Gastroenterological Association 2022 clinical practice guideline: phentermine has cardiovascular contraindications that disqualify many obesity patients
  - Endocrine Society 2015 obesity guideline (still current): step therapy through older anti-obesity agents is not clinically required for GLP-1 candidates with established comorbidities
  - Most plan-specific PA bulletins explicitly waive step therapy when the patient has documented prior trial OR contraindication

Procedural points

Per Florida Blue's own appeals process, I am submitting this appeal within the 180 days from denial notice window from the denial notice. I am requesting:

  1. A formal first-level internal appeal review of this denial
  2. Written notification of the appeal decision within the statutory turnaround
  3. If the denial is upheld at first level, automatic escalation to second-level internal review
  4. If the denial is upheld at second level, external review per state insurance law

I am available to discuss this case with the plan's medical director at [Prescriber phone] or [Prescriber email]. A peer-to-peer review is available at your request.

Conclusion

The patient meets the FDA-labeled criteria for this medication and indication. The clinical rationale is documented in the attached records. The denial reason cited does not reflect the documented clinical picture. I respectfully request that this denial be overturned and the prior authorization granted.

Thank you for your attention to this appeal.

Sincerely,

[Prescriber full signature]
[Prescriber printed name, credentials]
[Prescriber NPI]
[Practice name and address]

Attachments:
  - Original denial letter
  - Original prior authorization submission
  - Updated patient measurements and labs
  - Documentation directly addressing the denial reason cited
  - All clinical records supporting the requested treatment

Evidence to cite in the appeal

• American Gastroenterological Association 2022 clinical practice guideline: phentermine has cardiovascular contraindications that disqualify many obesity patients
• Endocrine Society 2015 obesity guideline (still current): step therapy through older anti-obesity agents is not clinically required for GLP-1 candidates with established comorbidities
• Most plan-specific PA bulletins explicitly waive step therapy when the patient has documented prior trial OR contraindication

The direct-rebuttal paragraph

The paragraph below is the heart of the appeal letter. It is what makes this appeal different from a generic re-submission. Adapt the bracketed clauses to the patient's specific findings.

The denial cites failure to meet step-therapy criteria. The patient has documented [prior phentermine trial with intolerance / contraindication to phentermine due to (specific cardiovascular condition with ICD-10) / contraindication to orlistat due to (specific GI condition with ICD-10)]. Per the plan's own PA criteria document, prior trial or documented contraindication satisfies the step-therapy requirement. The relevant documentation is attached.

Other appeal templates for Florida Blue

Same denial reason, other plans

Disclaimer

John Samaras, Founder and editorI started GLP Chart after overpaying for a GLP-1 myself. Based in Austin, Texas. About this site · LinkedIn · Contact