By Counterforce Health Team in StrataGraft (allogeneic cultured keratinocytes & fibroblasts in murine collagen-dsat) —

Do You Qualify for StrataGraft Coverage by UnitedHealthcare in Georgia? Decision Tree & Next Steps

Answer Box: Getting StrataGraft Covered by UnitedHealthcare in Georgia

Quick Answer: StrataGraft requires prior authorization through UnitedHealthcare's medical benefit (not pharmacy) for adults 18+ with deep partial-thickness thermal burns requiring surgical intervention. Submit via the UnitedHealthcare Provider Portal with wound measurements, photos, and burn surgeon documentation. If denied, Georgia residents have 60 days to file external review with the Georgia Department of Insurance. First step: confirm your diagnosis meets FDA criteria and gather required documentation.

Table of Contents

  1. How to Use This Decision Tree
  2. Eligibility Triage: Do You Qualify?
  3. If "Likely Eligible" - Document Checklist
  4. If "Possibly Eligible" - Tests to Request
  5. If "Not Yet" - Alternatives to Discuss
  6. If Denied - Appeal Path Chooser
  7. Coverage Requirements at a Glance
  8. Common Denial Reasons & Fixes
  9. FAQ: UnitedHealthcare StrataGraft Coverage in Georgia

How to Use This Decision Tree

This guide helps patients and clinicians determine if you qualify for StrataGraft coverage under UnitedHealthcare in Georgia, and provides clear next steps based on your specific situation.

Start here: Work through the eligibility questions below. Each section gives you specific actions based on your answers. If you're unsure about any medical details, consult your burn specialist before proceeding.

Note: StrataGraft is billed as a medical benefit (HCPCS J7353), not through pharmacy benefits. Attempting pharmacy billing will result in automatic denial.

Eligibility Triage: Do You Qualify?

Primary Requirements Checklist

Answer each question to determine your coverage likelihood:

✓ Age & Diagnosis

  • Patient is 18 years or older
  • Diagnosed with deep partial-thickness thermal burns (not superficial or full-thickness only)
  • Burns caused by thermal injury (flame, scald, contact) - not electrical, chemical, or chronic wounds

✓ Clinical Criteria

  • Burn surgeon confirms surgical intervention is clinically indicated
  • Wounds would ordinarily require split-thickness autograft
  • Conservative therapy (dressings, topicals) insufficient for timely healing
  • Treatment will occur at accredited burn center or hospital

✓ Documentation Ready

  • Wound measurements in cm² available
  • Clinical photographs with measurement scale
  • Total body surface area (TBSA) calculation documented
  • Prior treatment attempts and outcomes recorded

Your Result:

All boxes checked = "Likely Eligible" → Proceed to document checklist Missing 1-2 clinical items = "Possibly Eligible" → Request additional tests/documentation
Missing age/diagnosis requirements = "Not Yet" → Discuss alternatives with burn team Already denied = Skip to Appeal Path Chooser

If "Likely Eligible" - Document Checklist

Required Documentation Package

Burn Assessment Documentation:

  • Explicit diagnosis stating "deep partial-thickness thermal burns"
  • Anatomical locations and laterality (e.g., left forearm, anterior trunk)
  • Mechanism of injury clearly documented
  • TBSA percentage with calculation method (rule of nines, Lund-Browder)
  • Wound measurements for each StrataGraft site in cm²
  • High-quality clinical photographs with visible measurement scale and date labels

Medical Necessity Justification:

  • Statement that surgical excision and autografting are indicated by standard of care
  • Rationale for using StrataGraft to reduce/avoid autograft harvest
  • Documentation of limited donor sites or high donor-site morbidity risk
  • Description of prior wound management attempts and clinical course

Treatment Plan:

  • Planned site of care (burn center/hospital) and treating surgeon
  • Anticipated timing relative to injury and other operative steps
  • Correct HCPCS J7353 units, ICD-10 codes, and provider information

Submission Process

  1. Verify Prior Authorization Requirement: Log into UnitedHealthcare Provider Portal and enter HCPCS J7353 with patient's plan details
  2. Submit Complete Package: Upload all documentation via portal's "Prior Authorization and Notification" section
  3. Request Expedited Review: If surgical timing is urgent, mark as expedited with clinical justification
  4. Track Response: Standard review typically 14 days; expedited within 72 hours
Tip: For urgent burns, include physician attestation that delay would seriously jeopardize patient health or ability to regain maximum function.

If "Possibly Eligible" - Tests to Request

Missing Documentation to Obtain

If wound depth assessment incomplete:

  • Request burn surgeon evaluation with depth confirmation
  • Consider operative assessment if depth remains unclear
  • Obtain additional clinical photographs showing burn characteristics

If TBSA calculation missing:

  • Have burn team calculate using standardized method
  • Document percentage for total burns and specifically for deep partial-thickness areas
  • Include body diagram with measurements

If prior therapy documentation insufficient:

  • Compile complete treatment timeline with dates and outcomes
  • Document any complications or risk factors affecting healing
  • Obtain records from referring facilities if initial care was elsewhere

Timeline for Re-application

  • Gather missing documentation: 1-2 weeks typically required
  • Clinical reassessment: May be needed if significant time has passed since injury
  • Resubmit PA: Allow 2-3 weeks total from identification of missing items to resubmission

If "Not Yet" - Alternatives to Discuss

When StrataGraft May Not Be Appropriate

Age Requirements:

  • Patients under 18: StrataGraft is FDA-approved for adults only
  • Discuss standard autografting or other pediatric burn protocols

Burn Characteristics:

  • Superficial partial-thickness only: May heal with conservative care
  • Full-thickness burns: Typically require autograft; StrataGraft not indicated
  • Non-thermal wounds: Consider other skin substitutes appropriate for wound type

Clinical Timing:

  • Wounds healing well with conservative care: Continue current management
  • Extensive full-thickness burns requiring immediate autograft: StrataGraft may be adjunctive only

Preparing for Future Exception Requests

If clinical circumstances change:

  • Document progression of wound healing attempts
  • Track any complications that might justify StrataGraft use
  • Maintain relationship with burn specialist for reassessment

Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals. Their platform helps identify denial basis and drafts point-by-point rebuttals aligned to each plan's specific rules, pulling the right citations and clinical evidence to support your case.

If Denied - Appeal Path Chooser

Level 1: Internal Appeal (UnitedHealthcare)

Timeline: File within 180 days of denial date for commercial plans How to Submit: UnitedHealthcare Provider Portal or fax (number in denial letter) Required Documents:

  • Copy of denial letter
  • Burn surgeon letter addressing each denial reason
  • Any additional clinical documentation
  • Corrected billing information if denial was due to wrong benefit channel

Level 2: Peer-to-Peer Review

When to Request: If Level 1 denied or for complex cases Process: Burn surgeon contacts UHC medical director directly Preparation: Review denial rationale; prepare clinical guidelines supporting StrataGraft use Timeline: Usually scheduled within 5-10 business days of request

Level 3: Georgia External Review

Eligibility: After completing UnitedHealthcare internal appeals Deadline: 60 days from final internal denial date (stricter than federal 4-month minimum) How to File: Submit application to Georgia Department of Insurance Cost: Free to consumer Decision Timeline: 30 business days standard; 72 hours if expedited for urgent cases

Contact Information:

  • Georgia DOI Consumer Services: 1-800-656-2298
  • Online complaint/inquiry forms available on OCI website
Important: Georgia's 60-day deadline is firm. Mark your calendar immediately upon receiving final denial.

Coverage Requirements at a Glance

Requirement Details Documentation Needed Source
Prior Authorization Required for all plans Submit via UHC Provider Portal UHC PA Requirements
Age 18+ years only Birth date in medical record FDA Label
Diagnosis Deep partial-thickness thermal burns Burn surgeon assessment, photos FDA Label
Billing Code HCPCS J7353 per cm² Wound measurements Medical benefit, not pharmacy
Site of Care Burn center or hospital In-network verification UHC provider directory
Appeals Deadline 180 days internal; 60 days external Calendar tracking Georgia DOI regulations

Common Denial Reasons & Fixes

Denial Reason How to Fix Timeline
"Experimental/Investigational" Submit FDA approval documentation and Phase 3 trial data showing 96% autograft avoidance Include with appeal
"Wrong benefit channel" Resubmit as medical benefit using J7353, not pharmacy 24-48 hours for correction
"Insufficient medical necessity" Burn surgeon letter explaining why autograft alone is suboptimal 1-2 weeks for documentation
"Missing wound measurements" Provide detailed cm² calculations and clinical photos with scale Same day if measurements available
"Age requirement not met" Verify patient DOB; if under 18, discuss alternative treatments Not correctable for StrataGraft
From our advocates: We've seen denials overturned within 48 hours when the issue was simply wrong billing channel. The key is identifying whether it's a documentation problem (fixable) or a true coverage exclusion (requires appeal strategy).

FAQ: UnitedHealthcare StrataGraft Coverage in Georgia

Q: How long does UnitedHealthcare prior authorization take in Georgia? A: Standard review is typically 14 calendar days. Expedited review for urgent cases is completed within 72 hours when clinical urgency is documented.

Q: What if StrataGraft is non-formulary on my plan? A: StrataGraft is billed under medical benefit (J7353), not pharmacy formulary. If denied as non-formulary, resubmit using correct medical billing channel.

Q: Can I request expedited appeal if my burns are deteriorating? A: Yes. Both UnitedHealthcare internal appeals and Georgia external review offer expedited processes when delay would jeopardize health. Requires physician documentation of urgency.

Q: Does step therapy apply if I failed treatments in another state? A: Prior treatment failures should be accepted regardless of state, but documentation must be complete. Include all medical records showing failed conservative therapy.

Q: What are typical out-of-pocket costs for StrataGraft? A: Costs vary by plan. Expect to meet deductible ($1,000-$5,000 typical) plus coinsurance (10-20%). Check with Mallinckrodt for patient assistance programs.

Q: Who can prescribe StrataGraft? A: Must be prescribed by or in consultation with a burn specialist. Treatment must occur at qualified burn center or hospital facility.

Q: What happens if Georgia external review supports my case? A: The decision is binding on UnitedHealthcare. They must cover the treatment according to plan terms. This ends the administrative appeal process.

Q: Can I appeal if I'm on a Medicare Advantage plan? A: Yes, but Medicare Advantage follows different appeal levels (reconsideration, IRE, ALJ). Check your plan documents for specific timelines and processes.

For complex cases or additional support navigating the appeals process, Counterforce Health offers specialized assistance in building evidence-backed appeals that address payer-specific requirements and maximize approval chances.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage decisions depend on individual plan terms and clinical circumstances. Always consult with your healthcare provider and insurance company for specific guidance. For additional help with insurance appeals in Georgia, contact the Georgia Department of Insurance Consumer Services at 1-800-656-2298.

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