Fasenra denied by insurance? Appeal and win.
A Fasenra denial is the start of a process, not the end of it. This biologic is most often denied because the plan wants documented step therapy through inhaled controllers, a baseline blood eosinophil count on file, and prior-authorization criteria spelled out in the chart before it will approve a high-cost injectable. Appeals that map the patient's eosinophil level, exacerbation history, and failed prior therapies directly onto the plan's own written criteria are what flip these decisions.
Reviewed by the Apellica Appeals Team · Updated June 2026
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Fasenra (benralizumab) is FDA approved as an add-on maintenance treatment for adults and children aged 6 and older with severe asthma of an eosinophilic phenotype, meaning asthma driven by elevated eosinophils that stays uncontrolled despite standard inhaled therapy. It is also approved for adults with eosinophilic granulomatosis with polyangiitis (EGPA), and for adults and children aged 12 and older with hypereosinophilic syndrome (HES) that has no identifiable non-hematologic secondary cause. It is given as a subcutaneous injection and is not a rescue medication for acute bronchospasm or status asthmaticus.
Why Fasenra gets denied
- Step therapy not satisfied: the plan requires a documented trial and inadequate response to a high-dose inhaled corticosteroid plus a long-acting beta-agonist (and sometimes a second controller such as a LAMA or leukotriene modifier) before a biologic is approved.
- Eosinophilic phenotype not documented: a qualifying baseline blood eosinophil count (commonly 150 to 300 cells/mcL or higher per the policy) is missing, drawn while on oral steroids, or not recent enough to confirm the phenotype.
- Prior-authorization criteria not met on paper: the diagnosis, ICD-10 code, exacerbation history, and current controller regimen are not all clearly stated, so the reviewer cannot confirm severe eosinophilic asthma, EGPA, or HES.
- Non-formulary or biologic-of-choice step edit: the plan designates a different IL-5 pathway biologic (such as mepolizumab or dupilumab) as preferred and requires failure of that agent, or places Fasenra on a non-preferred tier, before covering it.
What a winning appeal includes
- A clear diagnosis with the correct ICD-10 code (for example J45.x severe persistent asthma, or the EGPA or HES code) plus a documented eosinophilic phenotype.
- A baseline blood eosinophil count drawn before or off systemic steroids that meets or exceeds the plan's threshold, with prior values to show the elevation is a pattern, not a one-off.
- A documented history of prior therapies tried and failed, including dates and outcomes for high-dose ICS/LABA and any add-on controllers, plus the number and severity of exacerbations or steroid bursts in the past 12 months.
- A letter of medical necessity from the prescribing specialist that quotes the plan's own criteria line by line and maps each requirement to the chart, including continuation-of-therapy data (reduced exacerbations or steroid use) for renewal denials.
How we approach the appeal
First identify whether the denial is a formulary or tier issue or a clinical prior-authorization denial, because the path differs. If Fasenra is non-formulary or non-preferred, file a formulary or tier exception arguing the patient meets the medical criteria and that preferred alternatives are inappropriate or have failed; if it is a PA or medical-necessity denial, request the plan's written coverage policy and answer each criterion point by point, quoting the plan's own language for eosinophil threshold and required step therapy. Attach the specialist's letter of medical necessity, the qualifying eosinophil labs, and the prior-therapy and exacerbation history, and escalate to peer-to-peer review and then external (independent) review if the internal appeal is upheld.
Fasenra appeal letter template
Copy this Fasenra appeal letter, fill in the brackets, and send it within your deadline. It is built on what overturns Interleukin-5 receptor alpha (IL-5Rα) antagonist monoclonal antibody denials.
[Date] [Your name] · Member ID [ID] · Rx claim # [#] [Insurer or PBM] - Appeals Department Re: Appeal of Fasenra denial I am appealing the denial of Fasenra (benralizumab). I request that the denial be overturned and Fasenra approved. 1. The denial. [Insurer] denied Fasenra stating, verbatim: "[paste the exact denial reason from your letter]." 2. Medical necessity. Fasenra is medically necessary for my condition. First identify whether the denial is a formulary or tier issue or a clinical prior-authorization denial, because the path differs. If Fasenra is non-formulary or non-preferred, file a formulary or tier exception arguing the patient meets the medical criteria and that preferred alternatives are inappropriate or have failed; if it is a PA or medical-necessity denial, request the plan's written coverage policy and answer each criterion point by point, quoting the plan's own language for eosinophil threshold and required step therapy. Attach the specialist's letter of medical necessity, the qualifying eosinophil labs, and the prior-therapy and exacerbation history, and escalate to peer-to-peer review and then external (independent) review if the internal appeal is upheld. 3. Step-therapy or formulary exception (if that was the reason): I have tried and failed [preferred drug(s)], with pharmacy records attached, or the preferred alternative is contraindicated because [reason]. I request a formulary or step-therapy exception. 4. My request. Approve Fasenra within the timeframe required by law. If the denial is upheld, please provide the specific criteria used, the reviewing clinician's credentials, and external-review instructions. Attached: prescriber letter of medical necessity, pharmacy and prior-trial records, and supporting clinical notes. Sincerely, [Your name]
Want it built and filed for you? Use the free generator, or have Apellica do it.
Internal appeals: 30 days pre-service, 60 days post-service, 72 hours urgent. File within 180 days of the denial.
$0 upfront. We assess fit first, then build and file the appeal for you.
- · The denial letter and your Explanation of Benefits (EOB)
- · Insurance ID, plan name, and the claim or prior-authorization number
- · Diagnosis with ICD-10 code and the prescriber's clinical notes
- · A record of treatments already tried and how they worked
Appealing a Fasenra denial by insurer
The path depends on who manages your benefit. The most common:
Coverage runs through the pharmacy benefit. Appeal the coverage determination and, when the drug is non-formulary, file a formulary or tier exception with a provider attestation that covered alternatives are unsuitable.
Publishes detailed prior-authorization criteria. A denial usually means a criterion was not documented. Appeal through a coverage review, with a formulary exception for excluded drugs.
Administers many UnitedHealthcare and employer plans. Appeals and exceptions follow the plan's published PA criteria; expedited review exists for urgent cases.
Internal appeal first, then independent external review. Pre-service decisions are generally made within 30 days, urgent within 72 hours.
Internal appeals and external review; pharmacy denials often route through OptumRx criteria.
Independent state plans, so criteria vary. Match the appeal to your specific BCBS plan, internal appeal first, then external review.
Frequently asked questions
Why does my insurance want me to fail inhalers first before covering Fasenra?
Most plans treat Fasenra as an add-on biologic, so their criteria require documented use of and inadequate control on a high-dose inhaled corticosteroid plus a long-acting beta-agonist (and sometimes another controller) first. If you have already tried those without control, the appeal should list each medication with dates and outcomes so the reviewer can confirm step therapy is satisfied. If a required step is medically inappropriate for you, your prescriber can request a step-therapy exception explaining why.
My eosinophil count was low when tested. Can I still get Fasenra approved?
It depends on why it was low and what the policy requires. Eosinophil counts are suppressed by oral or systemic steroids, so a value drawn during a steroid course may not reflect your true baseline. Appeals are stronger when they include an eosinophil count drawn off or before systemic steroids and any earlier elevated values that establish the eosinophilic phenotype over time. Your specialist can explain the timing in the letter of medical necessity.
Fasenra was approved before but my renewal got denied. What now?
Renewal or continuation denials usually turn on documentation that the drug is working. The appeal should show your response to therapy, such as fewer exacerbations, fewer oral-steroid bursts, or improved asthma control since starting Fasenra, which most plans accept as evidence of continued medical necessity. Include the dosing history and have the prescriber confirm ongoing benefit and the plan to continue.
Fasenra denied? We fight it for you.
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Start Your AppealThis page provides general information about appeal strategy. It is not legal or medical advice. Apellica is not a law firm. Outcomes depend on documentation, plan terms, and timing.