Rheumatology Prior Authorization and Denial Guide
Prior authorization requirements, denial patterns, and appeal strategies for rheumatology services, grounded in Aetna Medical Policy for biologics for rheumatoid arthritis and psoriatic arthritis, UHC CDG Rheumatology, Cigna Biologic DMARD Policy, eviCore Rheumatology criteria, and ACR/EULAR clinical guidelines for RA, PsA, AS, and SLE management.
Biologic DMARD prior authorization for rheumatoid arthritis: TNF inhibitors (adalimumab, etanercept, infliximab, certolizumab, golimumab), non-TNF biologics (abatacept, rituximab, sarilumab, tocilizumab), and JAK inhibitors (tofacitinib, baricitinib, upadacitinib) all require prior authorization with documentation of established RA diagnosis (ACR/EULAR 2010 criteria), DMARD failure (typically methotrexate at adequate dose for at least 3 months with documented inadequate response or intolerance), and recent disease activity assessment (DAS28-CRP, CDAI, or SDAI score). Step therapy is required by most payers — methotrexate or another conventional DMARD before biologic initiation, and often an initial TNF inhibitor trial before non-TNF biologics.
Infusion therapy: IV biologic infusions (infliximab CPT J1745, abatacept CPT J0129, tocilizumab CPT J3262, belimumab CPT J0485) require prior authorization and documentation of the approved indication and prior DMARD failure. Site-of-care requirements specify outpatient infusion center or office-based infusion for most commercial payers. Rituximab (CPT J9312) for RA requires documentation of TNF inhibitor failure and is approved for 2-course cycles, with prior authorization required for re-treatment.