By Counterforce Health Team in Revcovi (elapegademase) —

How to Get Revcovi (Elapegademase) Covered by Aetna CVS Health in Georgia: Complete Appeals Guide with Forms and Timelines

Answer Box: Getting Revcovi Covered in Georgia

Fastest path to approval: Submit Aetna's specialty medication precertification form with confirmed ADA-SCID diagnosis, specialist letter, and genetic/enzyme testing results. If denied, file internal appeal within 180 days, then Georgia external review within 60 days. Start today: Call 1-866-752-7021 (Aetna specialty precert) with member ID, diagnosis code D81.3, and prescriber details. Georgia Department of Insurance provides free external review if internal appeals fail.

Table of Contents

  1. Read Your Denial Letter
  2. Common Fixable Issues
  3. First-Level Appeal Strategy
  4. Peer-to-Peer Review Process
  5. Georgia External Review
  6. Appeal Templates & Scripts
  7. Tracking & Escalation
  8. Coverage Requirements at a Glance
  9. FAQ

Coverage Requirements at a Glance

Requirement What It Means Where to Find It Source
Prior Authorization Required for all Revcovi prescriptions Aetna member portal or denial letter Aetna Specialty Precert Form
Diagnosis Code D81.3 (ADA deficiency) required Lab reports, specialist notes FDA Label
Specialist Requirement Immunologist or ADA-SCID specialist Provider directory Aetna PA Policy
ADA Activity Level <1% of normal documented Lab report from CLIA-certified lab Mayo SCID Panel
Appeal Deadline (Internal) 180 days from denial Denial letter Aetna Appeals
External Review Deadline 60 days from final internal denial Georgia DOI form Georgia Insurance Rules

Read Your Denial Letter

Start by identifying the exact denial reason and benefit type. Aetna CVS Health denials typically fall into these categories:

Medical Benefit Denials (administered by Aetna):

  • "Not medically necessary"
  • "Experimental/investigational"
  • Missing specialist consultation
  • Insufficient diagnostic documentation

Pharmacy Benefit Denials (CVS Caremark):

  • Non-formulary medication
  • Step therapy not completed
  • Quantity limits exceeded
  • Prior authorization expired
Tip: Look for the appeals contact information in your denial letter. Commercial plans use different phone numbers than Medicare Advantage plans.

Key Information to Extract

  1. Member ID and plan type (commercial vs Medicare Advantage)
  2. Denial reason code and description
  3. Appeal deadline (usually 180 days for commercial, varies for Medicare)
  4. Required forms and submission method
  5. Expedited appeal eligibility criteria

Common Fixable Issues

Many Revcovi denials can be overturned by addressing documentation gaps:

Missing Diagnostic Confirmation

Problem: Aetna requires proof of ADA-SCID with enzyme activity <1% of normal or genetic confirmation.

Fix: Submit complete lab reports showing:

  • ADA enzyme activity from CLIA-certified lab
  • Genetic testing confirming pathogenic ADA variants
  • Lymphocyte subset analysis (T-, B-, NK- pattern)
  • ICD-10 code D81.3 in all documentation

Specialist Requirement Not Met

Problem: Revcovi must be prescribed by an immunology specialist.

Fix: Obtain consultation letter from:

  • Board-certified immunologist
  • Pediatric immunologist
  • Physician experienced in primary immunodeficiency management

Include the specialist's credentials and institutional affiliation in the appeal.

Incomplete Medical Necessity Documentation

Problem: Missing rationale for why Revcovi is required now.

Fix: Document why alternatives aren't appropriate:

  • HSCT unavailable or contraindicated
  • Gene therapy not accessible
  • Previous enzyme replacement failed
  • Bridge therapy needed before definitive treatment

First-Level Appeal Strategy

Aetna Commercial Plans

Contact Information:

  • Phone: 1-866-752-7021 (specialty precertification)
  • Fax: 1-888-267-3277
  • Timeline: 30-45 days for standard review

Required Documents:

  1. Completed appeal form
  2. Medical necessity letter from specialist
  3. Complete diagnostic workup
  4. Treatment history and failures
  5. Current clinical status

Medical Necessity Letter Checklist

Your specialist should address these points:

  • Confirmed ADA-SCID diagnosis with supporting lab values
  • Clinical presentation (infections, hospitalizations, growth)
  • Why Revcovi is standard of care (FDA approval, orphan designation)
  • Alternative therapies considered and why they're not suitable
  • Monitoring plan (ADA activity, lymphocyte counts, clinical response)
  • Treatment goals and expected outcomes
Clinician Corner: Include specific lab values in your letter. Target trough plasma ADA activity ≥30 mmol/hr/L and erythrocyte dAXP <0.02 mmol/L, as referenced in FEP BlueCross policy.

Peer-to-Peer Review Process

How to Request

Before Appeal: Call Aetna customer service (number on member ID card) and request peer-to-peer discussion.

During Appeal: Include "Request peer-to-peer review" on your appeal form.

Preparation Checklist

  • Member ID and denial reference number
  • Complete diagnostic timeline
  • Prior treatments tried and failed
  • Current clinical status
  • Specialist credentials and experience
  • FDA label and orphan drug designation

Key Talking Points

  1. FDA-approved indication: Revcovi is specifically approved for ADA-SCID
  2. Orphan designation: Ultra-rare, life-threatening condition
  3. No alternatives: Only FDA-approved enzyme replacement for ADA-SCID
  4. Standard of care: Enzyme replacement is accepted bridge/primary therapy
  5. Monitoring plan: Established lab targets and safety protocols

Georgia External Review

If your internal appeal fails, Georgia law provides independent external review through the Georgia Department of Insurance.

Eligibility Requirements

  • Completed internal appeal process
  • Denial based on medical necessity or experimental/investigational grounds
  • Request filed within 60 days of final internal denial
Important: Some guidance suggests 120 days, but Georgia regulations specify 60 days. Use the shorter deadline to be safe.

How to File

  1. Get the form: Contact Georgia DOI Consumer Services at 1-800-656-2298
  2. Required documents:
    • External review application
    • Copy of final internal denial letter
    • All supporting medical records
    • Specialist letters and evidence
  3. Submit: Follow instructions on the form (mail, fax, or online)

Timeline and Outcomes

  • Standard review: 30 days from complete submission
  • Expedited review: 72 hours for urgent cases
  • Success rate: Approximately 40-50% of specialty drug denials are overturned
  • Binding decision: If you win, Aetna must cover Revcovi

When to Request Expedited Review

Mark your application "EXPEDITED" if delaying Revcovi could:

  • Seriously jeopardize life or health
  • Risk severe infections due to immunodeficiency
  • Compromise ability to regain maximum function

Appeal Templates & Scripts

Patient Phone Script for Aetna

"Hello, I'm calling about a prior authorization denial for Revcovi for my [child/myself] with ADA-SCID. The member ID is [number]. I'd like to request a peer-to-peer review with the medical director and understand the appeal process. Can you transfer me to specialty pharmacy precertification?"

Medical Necessity Letter Template

Opening: "[Patient] has genetically confirmed adenosine deaminase severe combined immunodeficiency (ADA-SCID), ICD-10 D81.3, requiring FDA-approved enzyme replacement therapy."

Diagnosis: "ADA enzyme activity is <1% normal at [specific value]. Genetic testing confirms pathogenic ADA variants. Lymphocyte subsets show T-, B-, NK- pattern consistent with ADA-SCID."

Medical Necessity: "Revcovi is the only FDA-approved enzyme replacement for ADA-SCID. Without treatment, patients face life-threatening infections and typically fatal outcomes."

Alternatives: "HSCT is [not available/contraindicated/being evaluated]. Gene therapy is [not accessible/under consideration]. Enzyme replacement is medically necessary as [primary/bridge] therapy."

Monitoring: "We will monitor trough ADA activity (target ≥30 mmol/hr/L), dAXP levels (<0.02 mmol/L), and clinical response per FDA labeling."

Tracking & Escalation

Appeal Log Template

Date Action Contact Reference # Deadline Status
[Date] PA submitted Aetna [Number] [Date] Pending
[Date] Denial received - [Number] [Appeal by date] Need to appeal
[Date] Appeal filed Aetna Appeals [Number] [Decision by date] Under review

When to File a Complaint

Contact Georgia DOI Consumer Services if:

  • Aetna misses appeal deadlines
  • Required forms aren't provided
  • External review request is improperly denied
  • Coverage is denied after winning external review

Contact: 1-800-656-2298 or online complaint form

FAQ

Q: How long does Aetna CVS Health prior authorization take in Georgia? A: Standard PA decisions typically take 24-48 hours for complete submissions, up to 15 business days for complex cases. Source: Aetna PA policy

Q: What if Revcovi isn't on my formulary? A: Request a formulary exception with medical necessity documentation. If denied, this decision can be appealed and is eligible for Georgia external review.

Q: Can I request an expedited appeal? A: Yes, for urgent medical situations. Mark your appeal "EXPEDITED" and include physician statement explaining why delay could jeopardize health.

Q: Does step therapy apply to Revcovi? A: Step therapy may be required, but exceptions are available when other treatments are contraindicated or have failed. Document all prior therapies tried.

Q: What's the difference between CVS Caremark and Aetna denials? A: CVS Caremark handles pharmacy benefits (formulary, step therapy). Aetna handles medical benefits (medical necessity, experimental determinations). Check your denial letter to identify which entity made the decision.

Q: How much does Revcovi cost without insurance? A: Approximately $11,851 for 1.5 mL (directional cash price), though actual costs depend on dose and administration setting. Source: Drugs.com pricing

Getting Revcovi covered by Aetna CVS Health in Georgia requires persistence and proper documentation, but the state's external review process provides meaningful protection for patients with ADA-SCID. Counterforce Health helps patients and clinicians navigate insurance denials by turning them into targeted, evidence-backed appeals. The platform analyzes denial letters and plan policies to identify the specific reasons for coverage denials and drafts point-by-point rebuttals aligned to the plan's own rules.

When facing a Revcovi denial, remember that ADA-SCID is an ultra-rare, life-threatening condition with limited treatment options. Document the medical necessity thoroughly, engage specialist support, and use Georgia's consumer protections when needed. With proper preparation and the right evidence, many specialty drug denials can be successfully overturned.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and is not medical or legal advice. Coverage decisions depend on individual plan terms and medical circumstances. Consult your healthcare provider about treatment options and your insurance company about specific coverage requirements. For personalized help with insurance appeals, consider consulting with patient advocacy organizations or legal resources in Georgia.

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