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H.p. Acthar Gel denials: what the review data shows
Independent reviewers have decided 38 published cases where an insurer denied H.p. Acthar Gel — and they overturned the insurer 44.7% of the time. A denial for H.p. Acthar Gel is a starting position, not a final answer.
Published decisions
38
2001–2026
Overturned
44.7%
17 denials reversed
Conditions behind h.p. acthar gel denials
What insurers denied — and how those fights ended.
| Category | Decisions | Overturned |
|---|---|---|
| Rheumatoid Arthritis | 4 | 0% |
| Relapsing Remitting Multiple Sclerosis | 4 | 75% |
| Systemic Lupus Erythematosus | 3 | 33.3% |
| Sarcoidosis | 3 | 33.3% |
| Nephrotic Syndrome | 3 | 66.7% |
What the insurer actually argued
Denials fall into different categories, and they don’t succeed equally — so the reason on your letter changes how you should answer it.
| Reason given | Decisions | Overturned |
|---|---|---|
Medical Necessity The plan said the care wasn’t medically necessary. The most common fight, and the most winnable. | 35 | 48.6% |
Experimental/Investigational The plan called the treatment unproven. These turn on published evidence, so the appeal is a literature argument. | 3 | 0% |
Typical time to a decision
6 days
Most land between 4 and 14 days
Handled as urgent
71.1%
Expedited when a delay would cause harm
What the reviewers wrote
Excerpts from the independent reviewers’ published findings — the actual reasoning, quoted, not summarised.
Where the denial was overturned
Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for HP Acthar gel 80 Unit/mL (2 x 5 mL vials), injected twice per week. Psoriasis is a chronic inflammatory skin disease that typically presents with sharply demarcated, inflammatory, erythematous plaques with characteristic silver-white scaling due to epidermal hyperproliferation. Psoriasis has a high negative impact on the quality of life, especially in patients with moderate or severe disease. Long-term use of traditional systemic therapies is frequently unacceptable due to side effects and limited efficacy. Although there are numerous agents available, for patients with refractory disease that continue to experience tender and/or swollen joints, pain, and disease activity, HP Acthar gel may be indicated.
Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for HP Acthar Gel 80 units subcutaneously twice a week. The U.S. Food and Drug Administration approves the use of Acthar Gel for rheumatic disorders and diseases, such as systemic lupus erythematosus (SLE) flares. In a study of the use of Acthar Gel in SLE treatment, Li and colleagues concluded that their study “suggests a role for Acthar Gel as an alternative to corticosteroids in the treatment of SLE.
Where the denial was upheld
Worth reading too — these show what an appeal has to overcome.
Nature of Statutory Criteria/ Case Summary: The enrollee is requesting authorization and coverage for the medication, HP Acthar Gel, 80 units twice a week. The enrollee has seronegative rheumatoid arthritis and systemic lupus erythematosus. The enrollee began treatment with prednisone and Plaquenil. Methotrexate and Enbrel were added, with partial benefit. The enrollee has trialed Humira, Cimzia and Actemra without benefit. Methotrexate was discontinued due to gastrointestinal upset. The enrollee was started on Simponi Aria intravenous infusions. She continues to take Plaquenil with significant control of her disease. Her rheumatologist is requesting HP Acthar Gel, 80 units/mL, to treat the enrollee’s systemic lupus erythematosus.
Nature of Statutory Criteria/ Case Summary: The enrollee has requested authorization and coverage for the medication, H.P Acthar Gel. The enrollee has a history of steroid induced diabetes mellitus type 2, and systemic lupus erythematosus (SLE). Her nephrologist is requesting approval of HP Acthar Gel due to worsening proteinuria, now in the nephrotic range. She has had previous unsuccessful treatments including steroids, CellCept, Plaquenil, and cyclosporine. Her physician indicates a renal biopsy showed immunoglobulin A (IgA) nephropathy. Current treatments are not managing her symptoms so her physician has prescribed Acthar with a goal of managing proteinuria with nephrotic syndrome. A kidney biopsy done showed focal segmental glomerulosclerosis associated with lgA nephropathy and/or prior lupus nephritis.
Figures and quotations on this page come from 42,749 published decisions in the California DMHC Independent Medical Review dataset. These are California outcomes — every state runs an equivalent external review, but the rates here are California’s. Excerpts are quoted verbatim from the public record and describe this treatment generally, not any individual case.
How to use this in your appeal
These are outcomes from California’s external review program — an independent physician panel that binds the insurer. Every state has an equivalent process, and internal appeals succeed even more often. Cite the outcome record for H.p. Acthar Gelwhen you appeal: reviewers routinely find that denials like yours didn’t hold up.
SOURCE: CALIFORNIA DMHC INDEPENDENT MEDICAL REVIEW OUTCOMES (CHHS OPEN DATA) · DERIVED AGGREGATE STATISTICS ONLY · METHODOLOGY
Not legal or medical advice. Coverage Rights is a self-help tool that helps you prepare your own appeal. For advice about your specific situation, talk to a licensed attorney or your doctor.