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How to appeal prior authorization denial for Tymlos?
@mayblin suggested I start a new discussion since I wasn’t sure where to post this.
I just received a denial for prior authorization for Tymlos saying the medicine can only be approved if the patient has a diagnosis of postmenopausal women with osteoporosis (my hip is -3.8) at high risk of fracture. I fractured my femoral neck of hip and my wrist 5 months ago.
Unfortunately my Dexa says 10 year fracture risk not reported because some t-score for spine total or hip total or femoral neck at or below -2.5. My spine is -3.1 and my femoral neck is -2.4.
I was shocked by the denial. Should I first talk to my doctor on how to appeal this? Get a copy on the info doctor sent in? Any advice would be appreciated. Thanks so much.
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This is a good article on sequential therapy for osteoporosis which advises starting with anabolic therapy first:
https://academic.oup.com/jcem/article/109/2/303/7249092
My PA for Tymlos took over a month and then the insurance company cancelled it four months later and said I had to go on generic teriparatide (Forteo). It then took another three months to get the prescription filled due to issues with my rheumatologist's office team not submitting the prescription correctly.
I requested a referral to an endocrinologist at a local bone metabolic diseases clinic and she was able to get approval for Evenity within a week. There is definitely a difference in practitioners' ability to get approvals. In my case, I think the endocrinologist had established exactly what was needed to get approval and had credibility with my insurance company.
I'd recommend looking for an osteoporosis clinic in your area and getting an appointment with one of their specialists. There was a recent thread about where these clinics are located, at least in the US.
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