Inside Muni Appeals: The Infliximab Step Therapy Appeal That Scored 94/100

Why We're Showing You This

Step therapy denials are among the most frustrating for specialty practices. Insurers delay medically necessary biologics by requiring patients to "fail" cheaper alternatives first—even when clinical evidence supports immediate access to the prescribed medication.

We're doing something different: showing you exactly how Muni Appeals builds evidence-based arguments to bypass step therapy requirements, using a real example from our testing pipeline.

What we're revealing:

• The exact denial scenario (Humana step therapy for infliximab J1745)
• The research sources our system found (15+ authoritative citations)
• How we structure the argument (insurer contradictions → clinical evidence → federal benchmarks)
• Quality scoring methodology (5 dimensions scored)
• The final appeal letter output

What we're protecting:

• Our proprietary research pipeline (how we find and synthesize evidence)
• The AI models and prompt engineering
• Business logic and scoring algorithms

Think of this as: "Here's the quality of what we produce, but not the recipe for how we make it."

The Denial: Humana Step Therapy Requirement for J1745

Here's the exact denial letter our system processed:

The Legal Issue: This is a classic step therapy denial that may violate state laws and conflicts with Humana's own preferred drug listings. If Humana's published policies list infliximab (J1745) as "preferred" for rheumatoid arthritis, requiring patients to fail other medications first creates an internal contradiction.

What Makes This Complex:

Overturning this requires proving:

1. Humana's own policies list infliximab as a preferred agent for RA
2. Clinical evidence supports infliximab as first-line biologic therapy
3. Federal coverage benchmarks (CMS) recognize J1745 as medically necessary
4. Step therapy protocols cause harm by delaying appropriate treatment

Manual research for this takes 60-90 minutes. Muni Appeals found 15+ authoritative sources in 90 seconds. Here's what it found and how it built the appeal.

What Our System Found: 4 Layers of Evidence

Layer 1: Contradictions in Humana's Own Policies

The system identified that Humana's denial contradicts their published specialty drug lists:

Humana Specialty Drugs List - Category: Specialty Drugs:

"Preferred J1745 AND Remicade Preferred J1745 AND Simponi Aria Preferred"

Humana Injectable Drugs Step Therapy Guidance:

"Inflectra Preferred Q5103 Remicade Preferred J1745 Simponi Aria Preferred J1602"

Lists infliximab as preferred for autoimmune disorders including rheumatoid arthritis.

Humana Medicare Part B Preferred Drug List:

"Infliximab Preferred J1745 for Immunologic drugs – autoimmune disorders (arthritis, psoriasis, inflammatory bowel disease)"

Why this matters: The denial claims step therapy is required, but Humana's own published preferred drug lists designate J1745 infliximab as "preferred" for RA. The appeal leads with this internal contradiction—Humana can't simultaneously call infliximab "preferred" and deny access to it.

Layer 2: Clinical Evidence - Level I Studies

ATTRACT Trial (Landmark RCT):

In patients with active RA despite methotrexate, repeated infliximab infusions with methotrexate produced substantial clinical benefit and halted radiographic progression; at 54 weeks, 52% achieved ACR20 versus 20% with methotrexate alone (p<0.001).

Systematic Review - NIHR (UK National Institute for Health Research): Confirms the efficacy of biologic DMARDs, including infliximab, for RA, with significant reductions in disease activity and improvements in outcomes after conventional DMARD failure.

Meta-analysis - Infliximab Efficacy and Safety: Demonstrates robust ACR20 responses and favorable safety profile in moderate-to-severe RA with sustained benefits at one year.

Systematic Review - Infliximab in Early RA: Shows infliximab reduces disease progression with substantial ACR50 rates and low discontinuation for toxicity—underscoring the harm of delaying therapy.

Why this matters: Step therapy isn't just bureaucratic—it causes clinical harm. These studies show that delaying biologic therapy in RA leads to irreversible joint damage. The appeal cites this evidence to demonstrate that forcing patients to "fail first" on other medications is medically inappropriate.

Layer 3: Federal Coverage Benchmarks (CMS)

CMS Local Coverage Determination (LCD L35677): Provides coverage indications and medical necessity criteria for infliximab in RA (e.g., moderate-to-severe active disease), demonstrating national, regulator-backed standards for coverage.

CMS Billing and Coding Article A52423: Confirms coverage of infliximab (J1745) for FDA-approved indications such as RA when medically necessary, outlining billing/coding parameters that complement LCDs.

Why this matters: CMS policies aren't binding on commercial insurers, but they're highly persuasive. When Medicare covers infliximab for RA under specific criteria, commercial insurers like Humana typically mirror those standards. Citing CMS establishes federal recognition of medical necessity.

Layer 4: Comparative Studies - No Basis for Step Therapy

Comparative Meta-analysis Across Biologics: IV infliximab (J1745) is equivalent in efficacy and safety to other TNF inhibitors, validating it as a standard option without basis for unique access barriers.

Biosimilar vs. Biologic Comparison: No significant efficacy or safety differences between infliximab-biosimilar and other biologics in active RA—supporting broad access to TNF inhibitors, including J1745.

Real-World Dosing Flexibility: Dose-modification review shows infliximab dose escalations up to 10 mg/kg maintain efficacy with low serious adverse event rates, supporting clinical appropriateness and adaptability to patient needs.

Why this matters: If infliximab is therapeutically equivalent to Humira and Enbrel (which Humana wanted the patient to try first), there's no clinical rationale for forcing step therapy. The appeal uses this to argue that requiring failure on other TNF inhibitors is arbitrary cost-saving disguised as medical policy.

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The Complete Appeal Letter (94/100 Score)

Here's the actual appeal letter Muni Appeals generated in under 2 minutes. This scored 94/100 across our 5 quality dimensions. Every source cited below is real and clickable—verify for yourself.

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Why This Appeal Works: Strategic Breakdown

Now that you've seen the full letter, let's break down exactly why this approach is so effective against step therapy denials.

The Evidence Hierarchy Strategy

The system synthesized these sources into a 4-part argument, ordered by persuasive leverage:

1. Lead With Insurer's Own Policy Contradictions (Highest Leverage + Procedural Framing)

What we did: Opened with 3 direct quotes from Humana's own preferred drug lists showing that J1745 is explicitly designated as "preferred" for autoimmune disorders including RA.

Why this works: This frames the denial as a procedural error, not a clinical dispute. The issue isn't "should infliximab be covered?" (subjective medical necessity debate)—the issue is "Humana's step therapy denial contradicts their own preferred drug designation" (objective policy contradiction). This creates an impossible position for Humana. They cannot simultaneously:

• List infliximab as "preferred" for RA in their published drug lists, AND
• Deny access to infliximab by requiring patients to fail other medications first

The smoking gun quotes:

"Preferred J1745 AND Remicade Preferred J1745" — Humana Specialty Drugs List

"Infliximab Preferred J1745 for Immunologic drugs – autoimmune disorders (arthritis...)" — Humana Part B Preferred Drug List

When Humana's appeals department sees this, they're forced to either:

• Admit the step therapy requirement contradicts their own preferred drug designation, OR
• Explain how a "preferred" drug can simultaneously require failure on other agents first

This is the strongest leverage because it doesn't require debating clinical evidence—it's pointing out that Humana's denial contradicts Humana's own published policies.

2. Establish Clinical Harm of Delayed Treatment (Medical Urgency)

What we did: Cited 9 Level I studies (RCTs, systematic reviews, meta-analyses) showing:

• Infliximab is highly effective for RA (ATTRACT trial: 52% ACR20 vs 20% with MTX alone)
• Delays in biologic therapy cause irreversible joint damage
• Infliximab is equivalent in efficacy to other TNF inhibitors (no basis for preferring Humira/Enbrel)

Why this works: Step therapy isn't just bureaucratic delay—it causes real clinical harm. The systematic review in early RA explicitly states that delaying biologics leads to worse outcomes and irreversible joint damage.

The key clinical point:

"Systematic Review in Early RA: Shows infliximab reduces disease progression with substantial ACR50 rates and low discontinuation for toxicity—underscoring the harm of delaying therapy."

This transforms the appeal from "please approve" to "your step therapy protocol is causing medical harm to a patient who needs immediate treatment."

3. Invoke Federal Coverage Benchmarks (CMS Authority)

What we did: Referenced two CMS sources (LCD L35677 and Article A52423) that establish coverage criteria for infliximab in RA.

Why this works: While CMS policies are technically Medicare-only, commercial insurers routinely mirror CMS medical necessity criteria for specialty medications. When Medicare recognizes infliximab as medically necessary for RA under specific criteria, Humana can't easily argue it's not medically necessary for a commercial patient meeting the same criteria.

The regulatory leverage:

"While CMS policies are Medicare-focused and not binding on commercial plans, they are persuasive benchmarks that commercial carriers, including Humana, routinely mirror for biologics."

This signals: "We're not just asking you to approve based on our opinion—federal regulators already recognize this as medically necessary."

4. Dismantle the Step Therapy Rationale With Comparative Evidence

What we did: Included meta-analyses showing infliximab is therapeutically equivalent to adalimumab (Humira) and other TNF inhibitors.

Why this works: Humana's step therapy requirement is cost-driven (the denial explicitly notes infliximab costs $5,200/infusion vs Humira at $2,800/month). But if clinical evidence shows infliximab and Humira are therapeutically equivalent, there's no medical rationale for forcing step therapy—it's purely a cost-saving measure.

The comparative evidence:

"Comparative Meta-analysis: IV infliximab (J1745) is equivalent in efficacy and safety to other TNF inhibitors, validating it as a standard option without basis for unique access barriers."

This prevents Humana from arguing "we need patients to try Humira first because it works better"—the evidence shows they work equally well.

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The Timeline: 90 Seconds of Research, 2 Minutes Total

Here's how Muni Appeals processed this denial in under 2 minutes:

0:00-0:15 — Denial letter uploaded and parsed

• Extracted: Procedure code (J1745), insurer (Humana), denial reason (step therapy not met)
• Categorized denial type: Prior authorization / step therapy requirement

0:15-1:45 — AI research phase (90 seconds)

• Searched Humana policy database for J1745 preferred drug listings → Found 3 official documents showing "preferred" designation
• Queried PubMed for infliximab efficacy in RA → Found 9 Level I studies (RCTs, systematic reviews, meta-analyses)
• Searched CMS database for J1745 coverage criteria → Found 2 relevant sources (LCD + billing article)
• Searched for comparative TNF inhibitor studies → Found 3 meta-analyses showing therapeutic equivalence
• Total sources found: 15+ (all verified and linked)

1:45-2:00 — Letter generation and quality scoring (15 seconds)

• Structured argument using evidence hierarchy (Humana policy contradictions → clinical harm → federal benchmarks → comparative evidence)
• Drafted opening establishing the contradiction between "preferred" designation and step therapy denial
• Composed 4-part argument with direct quotes and source links
• Generated requested action with retroactive authorization language
• Scored across 5 dimensions (medical accuracy, evidence quality, legal soundness, hallucination risk, persuasiveness)
• Final score: 94/100 (threshold for approval: 85+)

Total time: 2 minutes

Compare this to manual research:

• Finding Humana preferred drug lists: 20-25 minutes
• PubMed literature search for RA biologics: 25-30 minutes
• CMS LCD search: 10-15 minutes
• Drafting and citing: 25-30 minutes
• Manual total: 80-100 minutes

That's a 40-50x time savings.

Quality Scoring: How We Validate Output

Every appeal letter gets scored across 5 dimensions before it's shown to the user. Here's what this example scored:

| Quality Dimension | Score | What We're Measuring | |---|---|---| | Medical Accuracy | 98/100 | Correct J1745 code, proper RA terminology, aligns with rheumatology standards | | Evidence Quality | 92/100 | Source authority (prioritizes insurer policies > Level I studies > govt sources), proper citation format | | Legal Soundness | 90/100 | Argument structure, regulatory citations, avoids unsupported legal claims | | Hallucination Risk | 99/100 | No fabricated statistics, all sources verified with URLs, no made-up policy numbers | | Persuasiveness | 95/100 | Logical flow, leads with strongest evidence (policy contradiction), clear requested action |

Overall Score: 94/100 (threshold for approval: 85+)

What the Scores Mean

Medical Accuracy (98): The appeal correctly uses J1745 for infliximab, references appropriate RA diagnostic criteria and treatment goals, and employs terminology consistent with rheumatology standards (ACR20 response, DMARD therapy, etc.). Near-perfect score reflects precise medical terminology.

Evidence Quality (92): Sources ranked by authority—Humana's own policies cited first (highest weight), followed by Level I clinical studies (RCTs, systematic reviews), then CMS policies. All 15+ citations include URLs and document names. Very high score reflects predominance of top-tier sources.

Legal Soundness (90): The retroactive authorization argument is structured appropriately, CMS sources cited as persuasive benchmarks (not binding law), and no unsupported legal claims made. Score reflects solid regulatory framework.

Hallucination Risk (99): Near-perfect score means virtually no fabricated data. Every statistic sourced to published studies, every policy citation verified with URLs, no made-up trial results. This is critical—some AI tools fabricate study outcomes.

Persuasiveness (95): The letter leads with Humana's policy contradictions (strongest leverage), then builds through clinical harm → federal benchmarks → comparative evidence. Structure forces Humana to address the internal contradiction before they can pivot to clinical arguments.

What Makes This Approach Different

1. We Catch the "Preferred" Drug Contradiction

The denial claims step therapy is required, but our system found 3 separate Humana policy documents that explicitly designate J1745 as "preferred" for RA. This contradiction is the most powerful leverage point in the entire appeal.

Finding this requires:

• Access to insurer policy databases (most practices don't have subscriptions)
• Knowledge of where to search (Humana publishes multiple drug lists across different portals)
• Time to cross-reference specialty drug lists, step therapy protocols, and Part B guidelines (20-30 minutes)

Muni Appeals found all of this in 90 seconds.

2. We Prioritize Clinical Harm, Not Just Efficacy

Many appeals simply argue "this drug works." Our system goes further: delaying biologic therapy in RA causes irreversible joint damage.

The systematic review citation specifically states:

"underscoring the harm of delaying therapy"

This reframes the appeal from "please approve our request" to "your step therapy protocol is causing medical harm."

3. We Use Federal Benchmarks as Persuasive Authority

While CMS policies aren't legally binding on commercial insurers, they carry enormous persuasive weight. When the appeal cites CMS LCD L35677 establishing coverage criteria for infliximab in RA, it signals:

"This isn't just our clinical opinion—federal regulators already recognize this as medically necessary."

Commercial insurers routinely mirror CMS medical necessity criteria to avoid coverage inconsistencies.

4. We Dismantle Cost-Based Denials With Comparative Evidence

Humana's denial explicitly notes the cost difference:

• Infliximab: $5,200/infusion
• Humira: $2,800/month

The appeal preempts the cost argument by citing meta-analyses showing therapeutic equivalence:

"IV infliximab (J1745) is equivalent in efficacy and safety to other TNF inhibitors"

If the drugs work equally well, requiring patients to try the cheaper option first is cost-shifting—not evidence-based medicine.

5. We Bind Insurers to Their Own Policy Framework

When you lead with an insurer's own policy contradictions—like citing Humana's "preferred" designation for J1745—you force them to defend against their published documents, not your clinical opinion.

This creates an internal bind:

• If they uphold the step therapy denial, they contradict their preferred drug listings
• If they overturn the denial, they validate your argument
• Either way, they can't pivot to vague "medical necessity" debates when their own policy framework supports coverage

This strategic framing shifts the burden of proof from you to the insurer. They must now explain why their step therapy protocol contradicts their preferred drug designation—a much harder position to defend.

This "bind" strategy works across different denial types and insurers—see how we apply it to BCBS medical necessity denials and Aetna frequency limitation denials with MHPAEA leverage.

6. We Don't Fabricate Data (99% Hallucination-Free)

This appeal scored 99/100 on hallucination risk, meaning:

• No made-up "studies show" claims without citations
• No fake trial results or ACR response rates
• No invented Humana policy numbers
• No fictional coverage precedents
• Every URL was verified before being cited

Click any link in the appeal above. They all work.

Transparency: What You're Seeing vs. What We Protect

What This Case Study Shows ✅

The Denial Input:

• Denial reason (step therapy not met for J1745 infliximab)
• Insurance company (Humana)
• Basic clinical context (RA patient, inadequate MTX trial)

The Research Sources:

• 15+ citations across 4 evidence types
• Specific Humana policy documents (3 preferred drug lists showing J1745 as "preferred")
• Clinical literature (9 Level I studies: RCTs, systematic reviews, meta-analyses)
• Federal benchmarks (2 CMS sources: LCD + billing article)
• Comparative effectiveness evidence (3 studies showing therapeutic equivalence)

The Output Quality:

• Scoring methodology (5 dimensions)
• Actual scores (94/100 overall)
• Feedback on strengths and weaknesses
• Final appeal letter structure

Why we show this: You can evaluate whether our output is medically accurate, legally sound, and properly evidenced. Transparency builds trust.

What We're Not Showing ❌

Our Research Pipeline:

• How we search and retrieve insurer policy documents across multiple portals
• Which AI models we use for evidence synthesis
• How we rank source authority automatically
• The prompts that guide evidence compilation

Our Scoring Algorithms:

• Exact criteria for each quality dimension
• How we detect hallucinations programmatically
• Thresholds for approval vs. rejection
• Multi-agent validation process

Our Business Logic:

• Proprietary knowledge of insurer policy database architecture
• Denial-type-to-evidence-strategy mapping
• Appeal structure optimization by insurer and denial category

Why we protect this: This is our competitive advantage—the encoded knowledge of appeal strategies, policy frameworks, and quality validation that took years to build.

The Bottom Line: Step Therapy Appeals That Work

This example demonstrates what Muni Appeals delivers for step therapy denials:

Speed: 2 minutes vs 80-100 minutes manual research (40-50x faster)

Rigor: 15+ authoritative sources across 4 evidence layers

Quality: 94/100 score with validated dimensions (medical accuracy, legal soundness, no hallucinations)

Strategy: Leads with insurer policy contradictions (Humana calls J1745 "preferred" but denies access)

Not a Black Box: You see what evidence we found and how we structured the argument—you just don't see the proprietary pipeline that makes it possible at scale.

Real-World Application

While this example uses a test scenario, the methodology applies to actual step therapy denials:

Rheumatology and specialty practices facing Humana step therapy denials can see exactly how we'd build a policy contradiction argument with preferred drug listings and clinical harm evidence.

Any specialty prescribing biologics or high-cost medications can understand our evidence hierarchy for step therapy: lead with insurer policy contradictions, establish clinical harm from delays, invoke federal benchmarks, dismantle cost-based arguments with therapeutic equivalence evidence.

Practices evaluating appeal automation can assess output quality through scoring transparency rather than taking marketing claims at face value.

Try the System Yourself

Upload a real denial letter. See the research sources, quality scores, and final appeal that our system generates for your specific case.

3 free appeals. No credit card required.

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Why This Matters for Specialty Practices

Step therapy denials are uniquely frustrating because:

1. They're cost-driven, not evidence-based (Humana's denial explicitly cites cost difference)
2. They delay medically necessary care (RA joint damage is irreversible)
3. They create administrative burden (providers must document "failure" on other medications)
4. They're often internally inconsistent (drugs designated "preferred" still require step therapy)

The result: Patients suffer delayed treatment, providers waste hours on appeals, and insurers bet on administrative attrition.

If you prescribe specialty medications (biologics, infusions, high-cost drugs), you should be systematically appealing step therapy denials when clinically inappropriate. Each successful appeal:

• Recovers revenue for your practice ($15,600-31,200 for a 3-month biologic course at typical infusion/injection rates)
• Gets patients on appropriate therapy faster, avoiding irreversible disease progression
• Establishes precedent with that insurer for future cases

This case study shows it's medically and strategically feasible—the challenge is finding time to do the research and write the appeals.

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Frequently Asked Questions

Is this a real patient case?

No. This is a test scenario we use to demonstrate our system's capabilities while maintaining HIPAA compliance. The denial letter, patient details, and clinical context are fictional. However:

• The appeal letter is real (generated by our actual system)
• The research sources are real (all 15+ links work and were found by our AI)
• The scoring is real (this letter genuinely scored 94/100)
• The methodology is real (this is exactly how we process step therapy denials)

We use test cases like this for product demos and quality assurance. Real patient cases would contain protected health information we cannot publish.

Why did this score higher (94) than the mental health example (92)?

Three reasons:

1. Stronger Policy Contradiction: Humana's "preferred" designation for J1745 creates a more direct internal contradiction than the Aetna mental health frequency cap example. When an insurer explicitly calls a drug "preferred," denying access via step therapy is harder to defend.

2. Higher-Quality Clinical Evidence: The infliximab evidence base includes landmark RCTs (ATTRACT trial), multiple systematic reviews from authoritative sources (NIHR), and specific meta-analyses on therapeutic equivalence. This is slightly stronger than the psychotherapy evidence base.

3. Near-Perfect Hallucination Score (99): Every clinical claim is sourced to verified studies with precise statistics (e.g., "52% ACR20 vs 20%, p<0.001"). No unsourced assertions.

The 2-point difference reflects these incremental quality improvements, not a significant gap in overall effectiveness.

How do you find insurer policy documents so quickly?

We can't reveal the full research pipeline (that's our competitive advantage), but at a high level:

• We maintain indexed databases of major insurers' policy documents
• Our system knows where to search across multiple portals (medical policies, pharmacy policies, provider manuals)
• We use specialized search algorithms to identify contradictions between denial reasons and published coverage criteria
• We cross-reference specialty drug lists, step therapy protocols, and medical policy bulletins automatically

Manual research requires:

• Knowing which documents exist (many providers don't)
• Finding login-protected portals or PDF databases
• Reading through 20-40 page policy bulletins to find relevant sections
• Cross-referencing multiple documents for contradictions

That's 20-30 minutes even for experienced billers. Our system does it in seconds.

Will this work for other step therapy denials?

Yes—the strategy is universal. Step therapy denials share common weaknesses:

1. Insurer Policy Contradictions (Most Common):

• Drug designated "preferred" but access blocked via step therapy
• Coverage criteria list the drug as medically necessary, but step protocols require failure on alternatives first

2. Clinical Harm from Delayed Treatment:

• Oncology: Delaying cancer treatment worsens outcomes
• Autoimmune diseases (RA, Crohn's, psoriasis): Irreversible damage from delays
• Neurologic conditions (MS): Disease progression during "try and fail" periods

3. Therapeutic Equivalence Evidence:

• If step therapy requires trying Drug A before Drug B, but they're therapeutically equivalent, the requirement is arbitrary cost-control

4. Federal Benchmarks:

• CMS coverage criteria apply to many specialty drugs (biologics, infusions, specialty pharmacy)

Same strategic framework, different sources based on your specific medication and diagnosis.

What if my state has step therapy reform laws?

Even better leverage. Several states have enacted step therapy reform laws requiring:

• Exceptions for drugs causing adverse events
• Exceptions when patient is stable on current therapy
• Clinical criteria-based overrides (not cost-based)

If your state has step therapy protections (e.g., California AB 265, Louisiana HB 188, New York S6531), Muni Appeals will automatically search for and cite applicable state law in the appeal.

Example states with step therapy reforms:

• California (AB 265 - Step Therapy Override)
• Louisiana (HB 188 - Step Therapy for Chronic Conditions)
• New York (S6531 - Step Therapy Override Process)
• Kentucky (HB 89 - Step Therapy Exemptions)
• West Virginia (HB 2263 - Step Therapy Protocol)

Our system identifies state-specific mandates when processing your denial and includes them in the appeal.

Can I try this exact case in your demo?

Yes. This Humana step therapy case is available in our demo mode. You can:

• Upload the same denial letter
• See the research sources our AI finds
• Review the generated appeal letter
• See the quality scoring breakdown
• No signup required for demo mode

We stock demo mode with multiple case studies covering different denial types (step therapy, medical necessity, prior auth, experimental exclusions) so you can see how Muni Appeals handles scenarios similar to your practice's denials.

Try the demo with this case

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How to Use This Knowledge for Your Practice

Even if you're not ready to try Muni Appeals, this case study teaches you what makes step therapy appeals succeed:

The Strategy You Can Apply Manually

1. Search for Insurer Policy Contradictions First

Before arguing clinical necessity, check if the insurer's step therapy requirement contradicts their published policies:

• Search "[Insurance Company] preferred drug list [medication name]"
• Look for specialty pharmacy protocols vs. medical policy bulletins
• Check Part B drug lists (often more permissive than Part D)

If you find contradictions (drug listed as "preferred" but denied via step therapy), lead with that—it's your strongest leverage.

2. Establish Clinical Harm from Delayed Treatment

Don't just argue "this drug works"—argue delays cause harm:

• Oncology: "Delaying second-line chemotherapy allows tumor progression"
• RA: "Delayed biologic therapy leads to irreversible joint damage"
• MS: "Step therapy trials during active disease worsen disability scores"

Cite systematic reviews showing worse outcomes with treatment delays.

3. Use Therapeutic Equivalence to Dismantle Cost Arguments

If step therapy requires trying Drug A before Drug B:

• Search for comparative effectiveness studies
• Find meta-analyses showing equivalent efficacy and safety
• Argue: "If equally effective, requiring failure on Drug A first is arbitrary cost-control, not evidence-based medicine"

4. Cite Federal Benchmarks (CMS)

For Medicare Advantage or to establish persuasive standards:

• Search CMS LCDs (Local Coverage Determinations) for your drug
• Reference CMS billing articles showing recognized indications
• Argue: "CMS establishes medical necessity criteria for [drug] in [condition]—commercial coverage should mirror federal standards"

5. Invoke State Step Therapy Laws (If Applicable)

Check if your state has step therapy reform:

• Search "[State] step therapy law" or "[State] step therapy override"
• Common exemptions: adverse events, stable on current therapy, clinical contraindication
• Cite state statute numbers in your appeal

This is exactly what Muni Appeals automates—but you can do it manually if you have 80-100 minutes per appeal.

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Ready to See It Work on Your Denials?

Stop spending 80-100 minutes per appeal researching insurer policies and clinical literature. See how much time and revenue your practice could save with our insurance appeal ROI calculator.

What happens when you try Muni Appeals:

1. Upload your denial letter (30 seconds)
2. Our system researches 15+ sources and drafts the appeal (1-3 minutes)
3. Review the sources, quality scores, and complete letter
4. Edit if needed, download, and submit to the insurer

The appeal letter you saw above? That's what you get—fully cited, strategically structured, ready to submit.

3 free appeals. No credit card required.

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This example case study demonstrates Muni Appeals methodology using a test scenario (Humana step therapy denial for infliximab J1745 in rheumatoid arthritis). Not based on real patient data. All sources cited are authentic and verifiable. Product methodology and scoring approach shown here apply to actual denial processing. Updated October 2025.