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

Get StrataGraft Covered by Aetna CVS Health in New Jersey: Complete Prior Authorization Guide with Forms and Appeals Process

Answer Box: Getting StrataGraft Covered by Aetna CVS Health in New Jersey

StrataGraft requires prior authorization from Aetna CVS Health in New Jersey for adults 18+ with deep partial-thickness thermal burns requiring surgical intervention. Submit via the Aetna provider portal using HCPCS code J7353 with burn surgeon documentation. If denied, New Jersey offers robust external review through IHCAP (Independent Health Care Appeals Program) with binding decisions. First step today: Have your burn center verify your Aetna plan details and gather wound measurements, clinical photos, and autograft contraindication documentation.

Table of Contents

  1. Start Here: Verify Your Plan and Find Forms
  2. Prior Authorization Forms and Requirements
  3. Submission Portals and Upload Process
  4. Fax Numbers and Mailing Addresses
  5. Appeals Process: Internal and External Review
  6. New Jersey External Review Rights (IHCAP)
  7. Support Lines and Who to Call
  8. Cost Assistance and Patient Support
  9. Common Denial Reasons and How to Fix Them
  10. FAQ: Most Asked Questions

Start Here: Verify Your Plan and Find Forms

Before beginning the StrataGraft approval process, confirm your specific Aetna plan type and coverage details.

Quick Plan Verification Steps

  1. Call Aetna Member Services at 1-800-872-3862 (TTY: 711) to verify:
    • Your plan type (commercial, Medicare Advantage, or Medicaid)
    • Medical benefit deductible and coinsurance rates
    • Whether your burn center is in-network
    • Current prior authorization requirements for HCPCS J7353
  2. Locate Your Plan Documents on the Aetna member portal to review:
    • Summary of Benefits and Coverage (SBC)
    • Prior authorization list for your specific plan year
    • Appeals and grievance procedures
Important: StrataGraft is billed under the medical benefit (HCPCS J7353), not through CVS Caremark pharmacy benefits. Attempting pharmacy billing results in automatic denial.

Prior Authorization Forms and Requirements

Coverage Criteria for StrataGraft

Requirement Details Documentation Needed
Age 18 years or older Date of birth verification
Diagnosis Deep partial-thickness thermal burns only Burn mechanism, TBSA %, depth assessment
Surgical Need Autograft clinically indicated but suboptimal Burn surgeon attestation
Wound Status Complete excision, hemostasis achieved, no infection Clinical photos with measurement scales
Facility Accredited burn center or hospital Facility billing confirmation
Allergies No known allergies to murine, bovine, or porcine products Medical history documentation

Required Documentation Checklist

  • Patient demographics and insurance information
  • Burn injury date, mechanism (heat, fire, steam, scalding)
  • Total body surface area (TBSA) percentage affected
  • Wound measurements in square centimeters
  • Clinical photographs with measurement scales
  • Burn surgeon's medical necessity letter
  • Documentation of autograft limitations or contraindications
  • Confirmation of no active wound infection
  • Allergy history (specifically murine/bovine/porcine)

Submission Portals and Upload Process

Aetna Provider Portal Submission

Primary Method: Submit through the Aetna provider portal using these steps:

  1. Log in to your Aetna provider account
  2. Select "Prior Authorization" from the main menu
  3. Choose "Medical Services" (not pharmacy)
  4. Enter HCPCS code J7353 for StrataGraft
  5. Upload all required clinical documentation
  6. Request expedited review if medically urgent (≤72 hours vs. standard 10-14 days)

EviCore Preauthorization (Northern New Jersey)

For providers in northern New Jersey, some Aetna plans require submission through EviCore:

  • Portal: evicore.com
  • Phone: Contact EviCore directly for account setup
  • Timeline: Same standards apply (expedited ≤72 hours, standard 10-14 days)

Fax Numbers and Mailing Addresses

Aetna Prior Authorization Contacts

Prior Authorization Fax: (verify current number with Aetna provider services) Mailing Address: Aetna Prior Authorization Department (confirm current address via provider portal)

Cover Sheet Tips:

  • Include "URGENT - StrataGraft HCPCS J7353" if requesting expedited review
  • List all attached documents with page counts
  • Include provider NPI and patient member ID
  • Add direct callback number for questions

Emergency Contact Information

Aetna Provider Services: 1-800-624-0756 Member Services: 1-800-872-3862 Prior Authorization Status: Available through provider portal or phone

Appeals Process: Internal and External Review

Aetna Internal Appeals

If your StrataGraft prior authorization is denied, you have 60 calendar days from the denial notice to file an internal appeal.

Standard Internal Appeal Process

  1. Gather Additional Evidence:
    • Updated burn surgeon letter addressing denial reasons
    • Additional clinical photos or wound measurements
    • Peer-reviewed literature supporting StrataGraft use
    • Documentation of failed alternative treatments
  2. Submit Appeal:
    • Online: Through Aetna provider portal
    • Phone: 1-844-362-0934 (TTY: 711)
    • Mail: Complete written appeal form
  3. Timeline:
    • Standard appeals: 30 calendar days for decision
    • Expedited appeals: 72 hours if delay would jeopardize health

Clinician Corner: Medical Necessity Letter

Your burn surgeon's letter should address these key points:

  • Clinical Problem: Specific burn characteristics and why standard care is insufficient
  • Prior Treatments: Documentation of why autograft alone is suboptimal
  • Clinical Rationale: How StrataGraft meets FDA-approved indications
  • Guideline Support: References to burn care protocols and FDA labeling
  • Treatment Goals: Expected outcomes and monitoring plan

New Jersey External Review Rights (IHCAP)

New Jersey offers excellent protection through the Independent Health Care Appeals Program (IHCAP) for external reviews when Aetna denies coverage.

IHCAP Process Overview

Eligibility: Available after completing Aetna's internal appeal process Timeline to File: 4 months (180 days) from final internal denial Review Entity: Maximus Federal Services (contracted by NJ DOBI) Cost: Free to patients and providers

How to File External Review

  1. Complete Internal Appeals First: Ensure you've exhausted Aetna's internal process
  2. Submit to Maximus: File directly with Maximus Federal Services (not NJ DOBI first)
  3. Include Documentation:
    • Copy of final Aetna denial letter
    • All medical records and clinical notes
    • Burn surgeon's updated medical necessity letter
    • Any additional supporting evidence

IHCAP Timeline and Decisions

Standard Review:

  • Preliminary review: 5 business days to confirm eligibility
  • Full review: 45 days from receipt of complete information
  • Decision: Binding on Aetna if overturned

Expedited Review:

  • Available when delay would cause serious harm
  • Preliminary review: "As soon as possible"
  • Full review: Typically within 1-2 weeks

Success Rates: About half of external appeals nationwide favor consumers, giving you strong odds with proper documentation.

New Jersey Consumer Support

NJ Department of Banking and Insurance (DOBI):

  • Consumer Hotline: 1-800-446-7467
  • IHCAP-Specific Line: 1-888-393-1062
  • Online Resources: Appeal and Complaint Guide for New Jersey Consumers

Support Lines and Who to Call

When to Call Each Number

Aetna Member Services (1-800-872-3862):

  • Verify coverage and benefits
  • Check prior authorization status
  • Request expedited review
  • General plan questions

Aetna Provider Services (1-800-624-0756):

  • Submit prior authorizations by phone
  • Request peer-to-peer reviews
  • Check claim status
  • Technical portal issues

New Jersey Consumer Help:

  • DOBI Consumer Hotline: 1-800-446-7467 for general insurance questions
  • IHCAP Line: 1-888-393-1062 for external review guidance

What to Ask When You Call

For Prior Authorization Status:

  • "What's the status of prior auth request for HCPCS J7353?"
  • "What additional documentation is needed?"
  • "Can this be expedited due to medical urgency?"

For Denials:

  • "What specific criteria weren't met?"
  • "Can you provide the exact policy language?"
  • "Is a peer-to-peer review available?"

Cost Assistance and Patient Support

Out-of-Pocket Cost Expectations

StrataGraft costs vary significantly based on your Aetna plan:

  • Deductible: Typically $1,000-$5,000 must be met first
  • Coinsurance: Usually 10-20% of the facility charge
  • Out-of-Network: Significantly higher costs if burn center isn't contracted

Mallinckrodt Patient Support

Contact Mallinckrodt directly for potential assistance programs:

  • Patient Support Services: Available through their main customer service
  • Financial Hardship Programs: May be available for eligible patients
  • Copay Assistance: Inquire about available support options
Tip: Many patients don't realize they can negotiate payment plans directly with the burn center for their portion of costs.

Common Denial Reasons and How to Fix Them

Denial Reason How to Overturn Required Documentation
"Not medically necessary" Burn surgeon letter detailing why autograft alone is insufficient Updated clinical photos, wound measurements, surgical plan
"Experimental/investigational" Cite FDA approval and HCPCS J7353 coverage FDA labeling, CMS coverage policies
"Non-formulary" Request medical benefit review (not pharmacy) Clarification that this is HCPCS J7353, not a drug
"Insufficient documentation" Submit complete clinical package All items from documentation checklist
"Outside approved indication" Confirm thermal burn diagnosis Burn mechanism documentation, exclude chemical/electrical

FAQ: Most Asked Questions

How long does Aetna prior authorization take in New Jersey? Standard review takes 10-14 business days. Expedited review (when medically justified) takes up to 72 hours. You can request expedited review if delays would jeopardize your health.

What if StrataGraft is listed as non-formulary? StrataGraft isn't on pharmacy formularies because it's billed as a medical procedure (HCPCS J7353), not a prescription drug. Ensure your burn center bills the medical benefit, not pharmacy.

Can I appeal if I'm denied? Yes. You have 60 days for internal appeals with Aetna, then 180 days for external review through New Jersey's IHCAP program. External review decisions are binding on Aetna.

Does step therapy apply to StrataGraft? Step therapy typically doesn't apply since StrataGraft is used when autograft is clinically indicated but suboptimal. However, documentation of why alternatives aren't appropriate strengthens your case.

What if my burn center isn't in Aetna's network? Out-of-network coverage may be available with higher cost-sharing. Request a network exception if no in-network burn centers in your area can provide StrataGraft treatment.

How much will I pay out-of-pocket? Costs depend on your specific plan's deductible and coinsurance rates. Contact Aetna member services with your plan details for an estimate based on your burn center's contracted rates.

Counterforce Health helps patients, clinicians, and specialty pharmacies navigate insurance approvals by turning denials into targeted, evidence-backed appeals. Our platform analyzes denial letters, plan policies, and clinical notes to draft point-by-point rebuttals aligned with each payer's specific requirements, pulling the right citations and clinical evidence to support coverage decisions.

For additional support navigating complex prior authorizations and appeals, Counterforce Health provides specialized expertise in insurance coverage strategies. Our team understands the nuances of payer-specific workflows and can help ensure your StrataGraft coverage request meets all procedural requirements while tracking critical deadlines.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage decisions depend on your specific plan terms, medical circumstances, and state regulations. Always consult with your healthcare providers and insurance representatives for guidance specific to your situation. Coverage policies and contact information may change; verify current details with official sources.

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