By Counterforce Health Team in Hetlioz LQ (tasimelteon oral suspension) —

Coding That Helps Get Hetlioz LQ (Tasimelteon) Approved by Humana in Florida: ICD-10, NDC, and Billing Guide

Answer Box: Getting Hetlioz LQ Covered by Humana in Florida

Hetlioz LQ (tasimelteon oral suspension) requires prior authorization from Humana Medicare Part D plans in Florida. The fastest path to approval: 1) Use ICD-10 code Q93.82 for Smith-Magenis syndrome with sleep disturbance codes (G47.0 for insomnia), 2) Submit weight-based dosing calculations with NDC 69336-0317-53, and 3) Include genetic testing confirmation and specialist documentation. Start today by having your prescriber contact Humana's PA department at 1-877-486-2621 with complete clinical documentation.

Table of Contents

Coding Basics: Medical vs. Pharmacy Benefit

Hetlioz LQ (tasimelteon oral suspension) is covered under Medicare Part D pharmacy benefits, not Part B medical benefits. This distinction is crucial for proper billing and authorization.

Key Points:

  • No J-code exists for Hetlioz LQ oral suspension
  • Bill using NDC numbers through pharmacy claims
  • Submit through Part D processes, not medical billing
  • Prior authorization is required for most Humana plans
Note: Unlike injectable medications that often have HCPCS J-codes, oral suspensions like Hetlioz LQ are processed as pharmacy benefits using National Drug Codes (NDCs).

ICD-10 Mapping for Smith-Magenis Syndrome

Proper diagnosis coding is essential for Hetlioz LQ approval. The primary indication is nighttime sleep disturbances in Smith-Magenis syndrome for pediatric patients aged 3-15 years.

Primary ICD-10 Codes

Condition ICD-10 Code Documentation Requirements
Smith-Magenis syndrome Q93.82 Genetic confirmation required (17p11.2 deletion or RAI1 mutation)
Insomnia/sleep initiation disorders G47.0 Document frequency, severity, impact on daily function
Obstructive sleep apnea G47.33 If present as comorbidity
Hypersomnia G47.1 For excessive daytime sleepiness

Documentation Words That Support Coding

When documenting for insurance approval, include these specific terms:

  • "Genetically confirmed Smith-Magenis syndrome"
  • "Inverted melatonin secretion pattern"
  • "Severe sleep-wake cycle disruption"
  • "Failed behavioral interventions"
  • "Functional impairment in school/home settings"

Product Coding: NDC, Units, and Calculations

NDC Information

  • Primary NDC: 69336-0317-53 (4 mg/mL oral suspension)
  • Manufacturer: Vanda Pharmaceuticals
  • Available sizes: 48 mL and 158 mL bottles

Weight-Based Dosing Calculations

Hetlioz LQ requires precise weight-based dosing for pediatric patients:

Dosing Formula:

  • ≤28 kg: 0.7 mg/kg once daily, one hour before bedtime
  • >28 kg: 20 mg (fixed dose) once daily, one hour before bedtime
  • Concentration: 4 mg/mL

Example Calculation: For a 20 kg child:

  • Dose: 20 kg × 0.7 mg/kg = 14 mg
  • Volume: 14 mg ÷ 4 mg/mL = 3.5 mL per dose
  • Monthly supply: 3.5 mL × 30 days = 105 mL

Billing Units

  • Bill by total mL dispensed per fill
  • Include patient weight in prescription
  • Specify exact dose volume for accurate adjudication

Clean Request Anatomy

A complete prior authorization request should include:

Required Clinical Information

  1. Patient Demographics
    • Age (must be 3-15 years)
    • Weight (for dosing calculation)
    • Humana member ID
  2. Diagnosis Documentation
    • ICD-10: Q93.82 (Smith-Magenis syndrome)
    • ICD-10: G47.0 (sleep disturbance)
    • Genetic test results confirming SMS
  3. Prescription Details
    • NDC: 69336-0317-53
    • Calculated dose in mL
    • "One hour before bedtime"
    • Quantity needed per month
  4. Clinical Justification
    • Prior therapy failures
    • Functional impact documentation
    • Specialist consultation notes
Clinician Corner: Your medical necessity letter should specifically address why Hetlioz LQ oral suspension is required over other formulations, emphasizing the pediatric indication and weight-based dosing requirements that cannot be achieved with capsules.

Frequent Coding Pitfalls

Common Errors to Avoid

Pitfall Fix Impact
Using wrong NDC for package size Verify current NDC with pharmacy Claim rejection
Missing patient weight Include weight on all prescriptions Dosing verification failure
Incorrect unit calculations Double-check mg to mL conversion Quantity limit issues
Using J-codes inappropriately Use NDC for oral suspension Wrong benefit category
Missing genetic confirmation Attach test results to PA Medical necessity denial

Unit Conversion Errors

The most frequent mistake involves converting between mg and mL:

  • Correct: 4 mg/mL concentration means 1 mL = 4 mg
  • Wrong: Assuming 1 mg = 1 mL dosing

Verification with Humana Resources

Before submitting claims or PA requests, verify current requirements:

Humana Provider Resources

  • Provider Portal: Check formulary status and PA requirements
  • Prior Authorization Fax: 1-877-486-2621 (verify current number)
  • Customer Service: Number on member's insurance card
  • Drug Formulary: Updated quarterly - confirm current tier placement

Cross-Check Steps

  1. Confirm Hetlioz LQ is on formulary
  2. Review current PA criteria
  3. Check for step therapy requirements
  4. Verify quantity limits
  5. Confirm NDC is covered

When working with patients who need specialized medications like Hetlioz LQ, Counterforce Health helps transform insurance denials into targeted, evidence-backed appeals by analyzing payer policies and crafting point-by-point rebuttals that address specific coverage criteria.

Quick Audit Checklist

Before submitting your Hetlioz LQ request, verify:

Patient Eligibility:

  • Age 3-15 years
  • Confirmed Smith-Magenis syndrome diagnosis
  • Weight documented for dosing

Coding Accuracy:

  • ICD-10 Q93.82 included
  • Sleep disturbance code added (G47.0 or appropriate)
  • Correct NDC: 69336-0317-53
  • Accurate dose calculation (mg and mL)

Documentation Complete:

  • Genetic test results attached
  • Prior therapy documentation
  • Specialist consultation notes
  • Functional impact assessment
  • Weight-based dosing justification

Submission Details:

  • Humana member ID correct
  • Prescriber information complete
  • PA form fully completed
  • All attachments included

Appeals Playbook for Florida

If your initial PA request is denied, Florida residents have specific appeal rights with Humana Medicare plans.

Internal Appeal Process

Timeline: 65 days from denial notice How to File:

  • Online through Humana member portal
  • Mail to address on denial letter
  • Fax: Use number provided in denial notice

Required Documents:

  • Original denial letter
  • Updated clinical documentation
  • Medical necessity letter
  • Any new supporting evidence

External Review (Florida)

If internal appeal fails, Florida residents can request external review through the Florida Department of Financial Services.

Timeline: 4 months after final internal denial Process: Independent medical expert reviews case Cost: No charge to consumer Contact: Florida Division of Consumer Services at 1-877-693-5236

Tip: For urgent cases involving pediatric medications like Hetlioz LQ, you can request expedited appeals that may be decided within 72 hours.

Escalation Resources

  • Florida Insurance Consumer Helpline: 1-877-MY-FL-CFO (1-877-693-5236)
  • Online Complaint Filing: Available through Florida DFS website
  • Consumer Advocate: Available through Florida CFO's office

The Counterforce Health platform specializes in turning these types of denials into successful appeals by identifying the specific denial basis and crafting evidence-backed responses that align with Humana's own coverage policies.

FAQ

How long does Humana prior authorization take for Hetlioz LQ in Florida? Standard PA decisions are typically made within 30 days for Part D medications. Expedited reviews can be completed within 72 hours if medical urgency is demonstrated.

What if Hetlioz LQ is non-formulary on my Humana plan? You can request a formulary exception by demonstrating medical necessity and that formulary alternatives are inappropriate or ineffective for your child's condition.

Can I request an expedited appeal if my child needs Hetlioz LQ urgently? Yes, if delay could seriously jeopardize your child's health, you can request expedited internal and external appeals simultaneously in Florida.

Does step therapy apply to Hetlioz LQ for Smith-Magenis syndrome? Step therapy requirements vary by plan, but given the specific pediatric indication and limited alternatives for SMS, many appeals successfully demonstrate that step therapy is inappropriate.

What happens if I can't afford the copay after approval? Vanda Pharmaceuticals offers patient assistance programs. Additionally, foundations like the National Organization for Rare Disorders may provide financial assistance for rare disease medications.

How do I prove my child's weight for dosing calculations? Include recent clinic visit notes with documented weight, or have your prescriber include weight measurements in the PA request documentation.

Can I appeal if Humana says the dosing is too high? Yes, provide the FDA-approved weight-based dosing calculations and reference the official prescribing information to demonstrate the dose is appropriate for your child's weight.

What if my child's geneticist is out-of-network with Humana? You can still use genetic testing and consultation from out-of-network providers for PA documentation, though you may need to pay out-of-pocket for those services.

Disclaimer: This information is for educational purposes only and does not constitute medical advice. Always consult with your healthcare provider and insurance plan for specific coverage details and medical guidance. Coverage policies and requirements may change.

Sources & Further Reading

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