By Counterforce Health Team in Evrysdi (risdiplam) —

Denied for Evrysdi (Risdiplam) by Humana in New York? How to Appeal (Forms, Templates & Timelines)

Answer Box: Getting Evrysdi (Risdiplam) Covered by Humana in New York

If Humana denied Evrysdi (risdiplam) for SMA treatment, you have strong appeal rights in New York. First step: Request internal appeal within 65 days using Humana's exceptions and appeals portal. Include genetic confirmation, baseline motor assessment (CHOP INTEND/HFMSE), and medical necessity letter. If denied again, file external appeal with NY Department of Financial Services within 4 months. Timeline: 72 hours for standard Humana decision, 24 hours expedited for urgent needs. New York's external review is binding on insurers.

Table of Contents

Coverage at a Glance: Evrysdi (Risdiplam) and Humana

Requirement What It Means Where to Find It Source
Prior Authorization Required for most specialty drugs Humana PA Search Tool Humana Provider Portal
Genetic Confirmation SMN1 homozygous deletion/mutation Medical records, genetic testing report FDA Label
Baseline Assessment CHOP INTEND or HFMSE scores Neurology clinic notes Clinical Guidelines
Age/Weight Documentation Weight-based dosing calculation Provider records FDA Prescribing Information
Appeal Deadline 65 days from denial notice Denial letter Medicare Guidelines
External Review 4 months after final denial NY DFS portal NY Insurance Law

Read the Denial: Decode Your Letter

When Humana denies Evrysdi (risdiplam), your denial letter contains critical information that determines your next steps. Look for these key elements:

Denial Reason Codes:

  • Not medically necessary: Most common for SMA treatments lacking genetic confirmation or baseline assessments
  • Non-formulary: Drug not on Humana's approved list (requires formulary exception)
  • Step therapy: Must try preferred alternatives first
  • Quantity limits: Dosing exceeds plan parameters

Benefit Type Determination: Evrysdi is typically covered under pharmacy benefit for home administration. If your denial mentions "medical benefit," verify with Humana whether this affects your appeal pathway.

Critical Deadlines:

  • Internal appeal: 65 days from denial date
  • External review: 4 months after final adverse determination
Tip: Screenshot or photocopy your denial letter immediately. You'll reference specific language and codes throughout the appeal process.

Fixable Causes: Common Issues

Many Evrysdi denials stem from documentation gaps rather than true medical necessity disputes. Here's how to identify and fix common problems:

Missing Genetic Confirmation

Problem: No SMN1 testing results in medical records Fix: Request genetic testing report from ordering physician; attach to appeal with interpretation

Incomplete Motor Assessment

Problem: Missing baseline CHOP INTEND or HFMSE scores Fix: Schedule assessment with pediatric neurologist; document current functional status

Dosing Documentation Gaps

Problem: Weight-based calculation not clearly documented Fix: Provider letter confirming current weight and FDA-approved dosing rationale

Duplicate Therapy Concerns

Problem: Concurrent or recent Spinraza/Zolgensma treatment Fix: Timeline documentation showing treatment sequence and medical rationale for switch

First-Level Appeal: Building Your Case

Your internal appeal to Humana should systematically address each denial reason with clinical evidence and policy citations.

Step-by-Step Appeal Process

  1. Gather Documentation (Days 1-7)
    • Original denial letter
    • Complete medical records from SMA diagnosis
    • Genetic testing confirmation
    • Baseline motor assessments
    • Provider treatment notes
  2. Request Medical Necessity Letter (Days 8-14)
    • Schedule appointment with prescribing neurologist
    • Review specific Humana denial reasons
    • Draft letter addressing each point (see template below)
  3. Submit Appeal (Days 15-21)
  4. Follow Up (Days 22-30)
    • Confirm receipt with Humana
    • Respond promptly to requests for additional information
    • Track decision timeline (72 hours standard, 24 hours expedited)

When preparing your appeal, Counterforce Health helps patients and providers turn insurance denials into targeted, evidence-backed appeals by analyzing denial letters and crafting point-by-point rebuttals aligned with each plan's specific policies and procedures.

Peer-to-Peer Call Strategy

If your written appeal is denied, request a peer-to-peer review where your prescribing physician speaks directly with Humana's medical director.

Preparation Checklist for Providers:

  • Patient's complete SMA history and progression
  • Specific contraindications to formulary alternatives
  • Clinical rationale for Evrysdi over Spinraza/Zolgensma
  • Baseline and follow-up motor assessment data
  • Treatment goals and monitoring plan

Key Talking Points:

  • FDA approval for pediatric and adult SMA patients
  • Patient-specific factors favoring oral therapy
  • Safety profile compared to intrathecal alternatives
  • Functional improvement or stabilization goals
From Our Advocates: In our experience helping families navigate SMA treatment appeals, peer-to-peer calls are most effective when providers focus on patient-specific clinical factors rather than general drug efficacy. One common successful approach involves documenting why intrathecal Spinraza isn't feasible due to spinal anatomy or access issues, making Evrysdi the most appropriate SMN2 modifier for that individual patient.

External Review in New York

If Humana upholds their denial after internal appeal, New York offers robust external review rights through the Department of Financial Services.

External Review Process:

Eligibility: Available after final adverse determination from Humana Deadline: 4 months from final denial Fee: $25 (waived for Medicaid or financial hardship) Timeline: 30 days standard, 72 hours expedited (24 hours for non-formulary drugs)

Required Documentation:

  • Completed NY External Appeal Application
  • All denial letters from Humana
  • Medical records supporting necessity
  • Physician attestation letter
  • Medical records release form

Submission Methods:

  • Online: DFS Portal
  • Fax: (800) 332-2729
  • Mail: NY Department of Financial Services, 99 Washington Avenue, Box 177, Albany, NY 12210

Key Advantage: External review decisions are binding on Humana. If overturned, they must provide coverage and refund your appeal fee.

For assistance with external appeals, contact Community Health Advocates at 888-614-5400 for free, expert guidance on New York insurance appeals.

Medical Necessity Letter Template

A compelling medical necessity letter should address Humana's specific denial reasons while establishing clear clinical rationale for Evrysdi.

Essential Components:

Patient Information & Diagnosis

RE: Evrysdi (risdiplam) Medical Necessity - [Patient Name]
DOB: [Date] | Policy: [Number] | Weight: [kg]

Dear Humana Medical Director,

I am requesting authorization for Evrysdi (risdiplam) for [Patient Name], diagnosed with spinal muscular atrophy confirmed by genetic testing showing [specific mutation/deletion].

Clinical Rationale Section

  • Current functional status with CHOP INTEND or HFMSE scores
  • Disease progression and treatment goals
  • Why Evrysdi is most appropriate (oral administration, home setting)
  • Contraindications to alternatives (if applicable)

Regulatory Compliance

  • FDA approval for SMA in pediatric and adult patients
  • Confirmation patient meets safety criteria (not on invasive ventilation except sleep/naps)
  • Weight-based dosing calculation per FDA label

Monitoring Plan

  • Schedule for reassessment (typically 6-month intervals)
  • Objective measures for continued medical necessity
  • Provider commitment to documentation

Resources for medical necessity letters are available through Genentech's provider portal and Counterforce Health's platform, which helps clinicians draft targeted appeals using the right evidence and clinical facts aligned to each payer's specific requirements.

Tracking Your Appeal

Maintain detailed records throughout your appeal process:

Appeal Log Template:

  • Date submitted: [Date]
  • Method: Portal/Fax/Mail
  • Confirmation number: [If provided]
  • Documents included: [List]
  • Follow-up date: [Calculate based on timeline]
  • Decision received: [Date and outcome]
  • Next steps: [Internal appeal, external review, etc.]

When to Escalate:

If Humana misses decision deadlines or fails to follow proper procedures, file complaints with:

  • New York Department of Financial Services: Consumer hotline (800) 342-3736
  • CMS (for Medicare plans): 1-800-MEDICARE

If Your Appeal Fails

Even after external review, you have additional options:

Formulary Alternatives:

Work with your provider to evaluate covered SMA treatments and request exceptions if contraindicated.

Patient Assistance Programs:

  • Genentech Patient Foundation: Income-based assistance
  • Good Days: Copay and premium support for eligible patients
  • HealthWell Foundation: Disease-specific grants

Clinical Trial Consideration:

Explore ongoing SMA research through ClinicalTrials.gov for access to investigational treatments.

FAQ

How long does Humana prior authorization take for Evrysdi in New York? Standard requests: 72 hours after receiving complete documentation. Expedited requests: 24 hours for urgent medical needs.

What if Evrysdi is non-formulary on my Humana plan? Request a formulary exception through Humana's appeals process. Provide clinical justification for why formulary alternatives are inappropriate.

Can I request expedited appeal if my child's SMA is progressing rapidly? Yes. Document urgent medical need and request expedited review. Decisions must be issued within 24-72 hours depending on the type of appeal.

Does step therapy apply if we tried Spinraza outside New York? Medical records from any state are valid. Provide documentation of prior treatment attempts, outcomes, and reasons for discontinuation.

What counts as adequate genetic testing for Evrysdi approval? SMN1 homozygous deletion or compound heterozygous mutations confirmed by certified laboratory. Include copy number and interpretation in your appeal.

How much does external review cost in New York? $25 per appeal (maximum $75 per year). Fee is waived for Medicaid enrollees or financial hardship cases.

Can my doctor appeal on my behalf? Yes. Providers can submit appeals directly, but patient consent and involvement in the process is typically required.

What happens if Humana approves but limits quantity? If the approved quantity is insufficient for FDA-recommended dosing, appeal the quantity limit with weight-based dosing calculations and clinical rationale.

Sources & Further Reading

Medical Disclaimer: This information is for educational purposes only and does not constitute medical advice. Always consult with your healthcare provider regarding treatment decisions and insurance coverage options. Appeal processes and requirements may change; verify current procedures with your insurer and state regulators.

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