Jennifer, a bus dispatcher and receptionist in her 50s, was battling severe rheumatoid arthritis, breast cancer, and seven other chronic conditions when her insurer, Aetna through Meritain Health, denied her medically necessary Actemra infusion treatment. The insurer demanded she restart step therapy with Inflectra, despite a documented history of failing multiple similar medications, including Simponi Aria, Orencia, and Humira—any one of which should have qualified her for an exception.

Over the course of eight months, Jennifer’s rheumatologist submitted four letters of medical necessity and two formal appeals. The insurer ignored the requests and delayed processing, providing only one written response—123 days after the initial request and 104 days after the initial appeal—far exceeding the legal requirement of a determination within 2 business days.

The result was a 242-day gap in treatment she was supposed to receive every 4 weeks. Without Actemra, Jennifer experienced significant pain in her hands, ankles, knees, hips, elbows, shoulders, and back, making it increasingly difficult to do her job. Her RA also affects her lungs and eyes, worsening her vision and breathing and putting her at risk of an adverse event without immediate access to care.

Jennifer was referred to Claimable by her rheumatologist and was able to generate, review, and submit a patient appeal all in the same day. Claimable’s appeal strategy demonstrated that the denial decision was not compliant with the insurer’s own policy for step therapy requirements, which Jennifer had already met through a documented history of inadequate response to multiple step therapy medications. The appeal also underscored her right to a fast and fair review given the urgent need for care, and was copied to appropriate regulators and executives to maximize reach and impact.