By Counterforce Health Team in Crysvita (burosumab) —

Get Crysvita (Burosumab) Covered by UnitedHealthcare in Florida: Complete Decision Tree & Appeal Guide

Quick Answer: Do You Qualify for Crysvita Coverage?

Yes, if you have: Confirmed X-linked hypophosphatemia (XLH) or tumor-induced osteomalacia (TIO), genetic/biochemical testing showing PHEX mutations or elevated FGF23, specialist prescription, and serum phosphorus below normal range. First step: Have your endocrinologist submit prior authorization through UnitedHealthcare's provider portal with complete diagnostic documentation. Timeline: 15 days for standard review, 72 hours for urgent cases. If denied: Internal appeal within 180 days, then external review through Florida Department of Financial Services if needed.

Table of Contents

How to Use This Decision Tree

This guide walks you through UnitedHealthcare's specific requirements for Crysvita (burosumab) coverage in Florida. Start with the eligibility triage below, then follow the path that matches your situation. Each section includes specific documents, timelines, and next steps.

Important: This covers UnitedHealthcare commercial and Medicaid plans in Florida. Medicare Advantage may have slightly different requirements—verify with your specific plan.

Eligibility Triage: Do You Qualify?

✅ Likely Eligible

You probably qualify if you have all of these:

  • Confirmed diagnosis of X-linked hypophosphatemia (XLH) or tumor-induced osteomalacia (TIO)
  • Genetic testing showing PHEX gene mutation OR elevated FGF23 levels
  • Age 6 months or older (some policies require 2+ years)
  • Serum phosphorus below normal range for age
  • Prescription from endocrinologist or metabolic bone disease specialist
  • Not currently taking oral phosphate supplements or active vitamin D analogs

🔍 Possibly Eligible

You may qualify with additional testing if you have:

  • Strong clinical suspicion of XLH (family history, skeletal deformities, dental issues)
  • Biochemical evidence of renal phosphate wasting
  • Low serum phosphorus but missing genetic confirmation
  • Prior treatment failures with conventional phosphate/vitamin D therapy

⏳ Not Yet

You'll need more preparation if:

  • Diagnosis isn't confirmed with required testing
  • Currently taking oral phosphate or active vitamin D (must discontinue first)
  • Serum phosphorus is normal or high
  • No specialist involvement documented

If "Likely Eligible": Document Checklist

Your endocrinologist needs these documents for prior authorization:

Required Clinical Documentation

  • Genetic test results showing PHEX mutation or FGF23 level above 30 pg/mL
  • Recent lab work (within 3 months): serum phosphorus, calcium, alkaline phosphatase, PTH
  • TmP/GFR calculation demonstrating renal phosphate wasting
  • Clinical notes documenting XLH/TIO symptoms and physical findings
  • Treatment history showing discontinuation of oral phosphate/active vitamin D
  • Dosing plan based on patient weight and FDA labeling

Submission Path

  1. Provider submits PA through UnitedHealthcare provider portal
  2. Timeline: 15 business days standard, 72 hours if marked urgent
  3. Follow-up: Check portal for additional information requests
Tip: Request peer-to-peer review immediately if initial PA is denied. This often improves approval chances.

If "Possibly Eligible": Tests to Request

Work with your endocrinologist to obtain:

Essential Diagnostic Tests

  1. PHEX gene sequencing or comprehensive hypophosphatemia gene panel
  2. FGF23 level (must be drawn before starting phosphate/vitamin D supplements)
  3. Complete phosphate workup: TmP/GFR, fractional tubular reabsorption of phosphate
  4. Imaging studies if indicated (bone X-rays, dental evaluation)

Timeline to Reapply

  • Genetic testing results: 2-4 weeks
  • Biochemical confirmation: 1-2 weeks
  • Resubmit PA: As soon as results confirm diagnosis

Track these deadlines carefully—UnitedHealthcare requires current lab values (typically within 90 days) for approval.

If "Not Yet": Alternatives & Exception Requests

Immediate Alternatives

While preparing for Crysvita approval:

  • Conventional therapy: Oral phosphate + active vitamin D (but must stop before Crysvita)
  • Orthopedic support: Bracing, physical therapy for skeletal deformities
  • Dental care: Preventive treatment for dental abscesses common in XLH

Exception Request Strategy

If you don't meet standard criteria:

  • Medical necessity letter from specialist explaining why alternatives failed
  • Literature review supporting off-label use (for TIO cases)
  • Clinical trial data if applicable to your specific situation
From our advocates: We've seen cases where patients initially denied for "insufficient genetic testing" were approved after submitting comprehensive family history documentation and specialist letters explaining why genetic testing was inconclusive but clinical diagnosis was clear.

If Denied: Florida Appeals Path

Level 1: Internal Appeal

  • Deadline: 180 days from denial notice
  • Submit to: UnitedHealthcare appeals department via member portal or mail
  • Timeline: 30 days for standard, 72 hours for urgent cases under Florida's Patient Timely Access to Healthcare Act
  • Include: Medical necessity letter, additional clinical evidence, guideline citations

Level 2: Peer-to-Peer Review

  • Request within: 5-10 days of denial
  • Process: Your doctor discusses case directly with UHC medical director
  • Preparation: Have specialist ready with clinical guidelines and patient-specific rationale

Level 3: External Review

  • Eligibility: After exhausting internal appeals
  • Request through: Florida Department of Financial Services
  • Deadline: 120 days after final internal denial
  • Cost: Free to consumer
  • Timeline: 45 days standard, 72 hours for urgent cases

For help navigating these appeals, Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals by analyzing denial letters and drafting point-by-point rebuttals aligned to payer policies.

Coverage Requirements at a Glance

Requirement What UnitedHealthcare Needs Where to Find It Source
Prior Authorization Yes, required for all plans Provider portal submission UHC Policy
Age Requirement 6 months or older Birth certificate, medical records UHC Policy
Genetic Testing PHEX mutation or elevated FGF23 Lab reports from certified facility UHC Policy
Specialist Prescription Endocrinologist or metabolic specialist Prescriber credentials, consultation notes UHC Policy
Lab Monitoring Serum phosphorus below normal Recent lab results (within 90 days) FDA Label
Drug Interactions No oral phosphate/active vitamin D Medication reconciliation FDA Label

Common Denial Reasons & How to Fix Them

Denial Reason How to Overturn Required Documents
"Insufficient diagnostic evidence" Submit complete genetic/biochemical workup PHEX sequencing results, FGF23 levels, TmP/GFR calculation
"Not prescribed by specialist" Get endocrinologist consultation Referral letter, specialist evaluation notes
"Concurrent use with prohibited drugs" Document discontinuation of oral phosphate/vitamin D Updated medication list, pharmacist verification
"Serum phosphorus not monitored" Establish monitoring plan Lab schedule, provider commitment letter
"Medical necessity not established" Comprehensive clinical justification Symptom documentation, functional assessments, treatment goals

FAQ: UnitedHealthcare Crysvita Coverage in Florida

Q: How long does prior authorization take? A: Standard reviews take up to 15 business days. Urgent cases (where delay could harm health) are processed within 72 hours under Florida law.

Q: What if Crysvita isn't on my formulary? A: UnitedHealthcare typically covers Crysvita as a specialty drug requiring prior authorization. Non-formulary status may require additional documentation or formulary exception request.

Q: Can I get expedited appeals in Florida? A: Yes, if your condition could worsen without treatment. Florida's Patient Timely Access to Healthcare Act requires faster processing for urgent medical needs.

Q: Does step therapy apply to Crysvita? A: No, UnitedHealthcare doesn't require trying other treatments first for confirmed XLH or TIO cases.

Q: What if I'm denied after peer-to-peer review? A: Request external review through the Florida Department of Financial Services. This independent review is binding and free to consumers.

Q: Are there cost assistance programs? A: Yes, Kyowa Kirin offers the Crysvita Connect program for eligible patients, including copay assistance and prior authorization support.

Q: How do I file a complaint about delays? A: Contact the Florida Department of Financial Services Consumer Helpline at 1-877-MY-FL-CFO (1-877-693-5236) if UnitedHealthcare exceeds legal timelines.

Q: Can I appeal if I live in Florida but have coverage from another state? A: If you have a fully-insured UnitedHealthcare plan, Florida appeal rights apply. Self-funded employer plans follow federal ERISA rules but you can still get help from Florida consumer assistance.

When to Get Additional Help

Contact these resources if you need support:

  • UnitedHealthcare Member Services: Number on your insurance card
  • Florida Department of Financial Services: 1-877-MY-FL-CFO for appeal guidance
  • Crysvita Connect: Patient support program for coverage assistance
  • Counterforce Health: Specialized service that helps patients and providers turn insurance denials into successful appeals by analyzing payer policies and crafting targeted medical necessity arguments

Sources & Further Reading

Disclaimer: This information is for educational purposes only and doesn't constitute medical or legal advice. Insurance coverage varies by plan and individual circumstances. Always verify current policy requirements with UnitedHealthcare and consult your healthcare provider for medical decisions. For official Florida insurance regulations and consumer rights, visit the Florida Department of Financial Services website.

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