Counterforce Health Team

Myths vs. Facts: Getting Dupixent (dupilumab) Covered by UnitedHealthcare in California - Appeals Guide

Answer Box: Getting Dupixent Covered by UnitedHealthcare in California UnitedHealthcare requires prior authorization for Dupixent (dupilumab) with step therapy requirements varying by condition. For atopic dermatitis, you need documented failure of two topical therapies. For asthma, you must show poor control plus eosinophilic phenotype or steroid dependence. If denied, California

How to Get Strimvelis Gene Therapy Covered by Blue Cross Blue Shield in Ohio: Complete Appeal Guide with Forms and Timelines

Answer Box: Getting Strimvelis Covered in Ohio Strimvelis (ADA-SCID gene therapy) requires prior authorization from Blue Cross Blue Shield in Ohio, with appeals following a structured timeline: internal review (30 days), second-level appeal if needed, then external review through Ohio's Independent Review Organization (180-day deadline from final denial)

Get Elevidys Covered by UnitedHealthcare in Michigan: Complete Prior Authorization and Appeals Guide

Answer Box: Getting Elevidys Covered by UnitedHealthcare in Michigan UnitedHealthcare requires prior authorization for Elevidys (delandistrogene moxeparvovec-rokl) gene therapy, with mandatory step therapy through corticosteroids first. To get approved: (1) Document failed prednisone/prednisolone trials with doses and duration, (2) Submit genetic DMD confirmation and anti-AAVrh74 antibody testing showing titer

Coding That Helps Get Hemgenix (etranacogene dezaparvovec) Approved by Humana in Pennsylvania: ICD-10, HCPCS, and Billing Guide

Answer Box: Getting Hemgenix Covered by Humana in Pennsylvania Hemgenix (etranacogene dezaparvovec) requires prior authorization from Humana and bills under your medical benefit using HCPCS code J1411. Key steps: (1) Use ICD-10 code D67 for hemophilia B with documented factor IX levels ≤5 IU/dL, (2) Submit PA through Humana&

Getting Palynziq Covered by UnitedHealthcare in Pennsylvania: Complete Prior Authorization and Appeals Guide 2025

Quick Answer: Getting Palynziq Covered by UnitedHealthcare in Pennsylvania UnitedHealthcare requires prior authorization for Palynziq (pegvaliase-pqpz) with mandatory 4-week sapropterin trial first. If denied, Pennsylvania's new Independent External Review program overturns 50% of appeals. Start today: Have your PKU specialist gather blood phenylalanine levels >600 µmol/L,

How to Get Rylaze Covered by Aetna CVS Health in Michigan: Complete Prior Authorization and Appeals Guide

Answer Box: Getting Rylaze Covered by Aetna CVS Health in Michigan Rylaze requires prior authorization from Aetna CVS Health for patients with ALL/LBL who developed hypersensitivity to E. coli-derived asparaginase. The fastest path: (1) Submit Aetna's Rylaze precertification form with documented hypersensitivity records, (2) Request peer-to-peer review

Denied for Natpara by UnitedHealthcare in New Jersey? Complete 2025 Appeal Guide & Alternative Coverage Options

Answer Box: Natpara was discontinued by Takeda in December 2024, making new prescriptions impossible. If denied coverage for alternative parathyroid hormone treatments like Yorvipath, New Jersey patients can appeal through UnitedHealthcare's internal process (180 days), then New Jersey's Independent Health Care Appeals Program (IHCAP) via Maximus

Myths vs. Facts: Getting Kesimpta (Ofatumumab) Covered by Humana in Michigan

Answer Box: Getting Kesimpta Covered by Humana in Michigan Kesimpta (ofatumumab) requires prior authorization from Humana Medicare Advantage plans and typically sits at Tier 5 specialty coverage. Michigan residents have strong appeal rights through the Department of Insurance and Financial Services (DIFS), with 127 days to file external reviews after

How to Get Myozyme (Alglucosidase Alfa) Covered by Blue Cross Blue Shield in Pennsylvania: Forms, Appeals, and Success Strategies

Answer Box: Your Path to Coverage Getting Myozyme (alglucosidase alfa) covered by Blue Cross Blue Shield in Pennsylvania requires prior authorization with confirmed Pompe disease diagnosis via genetic testing and enzyme activity levels. Start today by: (1) calling your specific Blue plan (Highmark or Independence Blue Cross) to request the

Renewing Ruconest Approval with UnitedHealthcare in Virginia: 2025 Timeline, Documentation & Appeals Guide

Answer Box: Renewing Ruconest Coverage with UnitedHealthcare in Virginia UnitedHealthcare requires 12-month reauthorization for Ruconest with documented attack frequency over the past year. Start renewal 30-45 days before expiration. Submit attack logs, specialist notes, and current lab values through the UHC Provider Portal. If denied, appeal within 180 days, then