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

Getting StrataGraft Covered by Aetna CVS Health in Ohio: Complete Prior Authorization Guide and Appeals Process

Answer Box: Quick Eligibility Check

To get StrataGraft covered by Aetna CVS Health in Ohio, you must be 18+ with deep partial-thickness thermal burns requiring surgical intervention. Submit prior authorization through your burn center using HCPCS code J7353 (medical benefit, not pharmacy). Include clinical photos, wound measurements, and burn surgeon documentation. If denied, you have 180 days to appeal internally, then can request external review through the Ohio Department of Insurance. Start today: Call Aetna member services at the number on your insurance card to confirm current PA requirements.

Table of Contents

  1. Eligibility Decision Tree
  2. If You're Likely Eligible
  3. If You're Possibly Eligible
  4. If You're Not Yet Eligible
  5. If Your Claim is Denied
  6. Common Denial Reasons & Solutions
  7. Ohio Appeals Process
  8. What to Gather Before Starting
  9. FAQ
  10. Resources

Eligibility Decision Tree

Step 1: Basic Requirements Check

Age: Are you 18 years or older?

  • ✅ Yes → Continue to Step 2
  • ❌ No → StrataGraft is not FDA-approved for pediatric patients. Discuss alternative burn treatments with your physician.

Burn Type: Do you have thermal burns (from heat, fire, steam, or scalding)?

  • ✅ Yes → Continue to Step 2
  • ❌ No → StrataGraft is only indicated for thermal burns, not chemical, electrical, or other wound types.

Step 2: Clinical Severity Assessment

Burn Depth: Has your burn specialist confirmed deep partial-thickness burns with intact dermal elements?

  • ✅ Yes → Continue to Step 3
  • ❓ Uncertain → Request burn depth assessment from qualified burn specialist
  • ❌ No → Superficial burns don't qualify for StrataGraft coverage

Surgical Indication: Has your physician documented that surgical intervention is clinically indicated?

  • ✅ Yes → Continue to Step 3
  • ❓ Uncertain → Request written surgical consultation from burn specialist
  • ❌ No → Conservative wound care may be more appropriate

Step 3: Treatment History

Autograft Status: Is autografting unavailable or medically contraindicated for your case?

  • ✅ Yes → You're Likely Eligible - proceed to approval pathway
  • ❓ Uncertain → You're Possibly Eligible - additional evaluation needed
  • ❌ No → Standard autografting may be preferred first-line treatment

If You're Likely Eligible

Congratulations! You meet the primary criteria for StrataGraft coverage. Here's your fastest path to approval:

Document Checklist

Required Clinical Documentation:

  • Burn depth assessment confirming deep partial-thickness burns
  • Clinical photographs with measurement scales visible
  • Wound measurements in square centimeters
  • Total body surface area (TBSA) calculation
  • Documentation of why autografting is contraindicated or unavailable
  • Written attestation from burn specialist that surgical intervention is indicated
  • Confirmation of no allergies to murine, bovine, or porcine products

Submission Process

  1. Contact your burn center's prior authorization team to initiate the PA request
  2. Verify billing method: Ensure they'll bill as medical benefit using HCPCS code J7353
  3. Submit through Aetna's provider portal with complete documentation package
  4. Timeline: Standard review takes 10-14 business days; expedited review available for urgent cases (72 hours)
Tip: The most common approval delay is incomplete clinical photography. Ensure photos include measurement scales and clearly show burn depth.

If You're Possibly Eligible

You may qualify with additional documentation. Focus on these areas:

Additional Tests to Request

  • Burn biopsy to confirm depth if visual assessment is unclear
  • Donor site evaluation to document limited autograft availability
  • Allergy testing if history of reactions to animal products is unclear
  • Surgical consultation with detailed written assessment of treatment options

Timeline for Re-evaluation

Most additional testing can be completed within 1-2 weeks. Once you have complete documentation, return to the "Likely Eligible" pathway above.

If You're Not Yet Eligible

Don't lose hope. Here are alternative approaches:

Alternative Treatments to Discuss

  • Split-thickness autografts from available donor sites
  • Temporary biologic dressings while preparing for definitive treatment
  • Staged surgical approach if extensive burns limit immediate grafting options

Preparing for Exception Requests

If standard treatments fail or are contraindicated, document:

  • Specific medical reasons why alternatives won't work
  • Previous treatment failures with detailed outcomes
  • Physician attestation supporting StrataGraft as medically necessary

If Your Claim is Denied

Don't panic. Counterforce Health helps patients navigate complex insurance denials by turning them into targeted, evidence-backed appeals. The platform analyzes denial letters and crafts point-by-point rebuttals using the right clinical evidence and payer-specific requirements.

Internal Appeal Process (First Step)

  1. File within 180 days of receiving denial notice
  2. Request peer-to-peer review with Aetna's medical director
  3. Submit additional evidence addressing specific denial reasons
  4. Timeline: 30-45 days for standard review; 72 hours for expedited appeals

External Review (If Internal Appeal Fails)

Ohio residents have strong appeal rights through the Ohio Department of Insurance:

  • Timeline: 180 days from final internal denial to request external review
  • Process: Independent Review Organization (IRO) conducts medical review
  • Decision timeline: 30 days for standard review; 72 hours for expedited
  • Cost: Free to patients
  • Contact: Ohio DOI Consumer Services at 800-686-1526

Common Denial Reasons & Solutions

Denial Reason Solution Strategy
"Not medically necessary" Submit burn depth photos, wound measurements, and specialist consultation documenting surgical need
"Experimental/investigational" Provide FDA approval documentation and clinical trial efficacy data
"Alternative treatments available" Document contraindications to autografting or previous treatment failures
"Wrong billing code" Resubmit using HCPCS J7353 through medical benefits, not pharmacy
"Insufficient documentation" Complete clinical package with photos, measurements, and specialist notes

Ohio Appeals Process

Ohio provides robust consumer protections for insurance appeals:

Internal Appeals with Aetna

  • First level: 180 days to file, 30-day decision timeline
  • Expedited: Available for urgent medical situations, 72-hour decisions
  • Required: Must complete internal appeals before external review

Ohio External Review

  • Eligibility: Available after final internal denial
  • Timeline: 180 days to request, 30 days for decision
  • Binding: IRO decisions are binding on insurers
  • Free: No cost to patients

When to Escalate

Contact Ohio DOI if:

  • Aetna refuses to accept your appeal
  • Deadlines are missed without justification
  • You need help understanding your rights

What to Gather Before Starting

Insurance Information:

  • Aetna member ID card
  • Policy number and group number
  • Summary of Benefits and Coverage (SBC)

Medical Records:

  • Burn injury documentation with date and mechanism
  • Clinical photographs of wound sites
  • Previous treatment records and outcomes
  • Specialist consultation notes

Contact Information:

  • Burn center prior authorization department
  • Aetna member services number
  • Your assigned case manager (if applicable)
From our advocates: "We've seen the biggest difference when families get organized early. One patient in Ohio had their StrataGraft approved on first submission because their burn center submitted clinical photos with proper measurement scales and detailed surgical consultation notes. The key was having everything ready before the PA request went in."

Clinician Corner: Medical Necessity Documentation

Healthcare providers should include these elements in StrataGraft medical necessity letters:

Clinical Assessment:

  • Burn mechanism and date of injury
  • Total body surface area (TBSA) affected
  • Burn depth classification with supporting evidence
  • Wound measurements in square centimeters

Treatment Rationale:

  • Why autografting is contraindicated or unavailable
  • Previous treatments attempted and outcomes
  • Expected benefits of StrataGraft over alternatives
  • Surgical plan and timeline

Supporting Evidence:

Frequently Asked Questions

How long does Aetna CVS Health prior authorization take in Ohio? Standard prior authorization takes 10-14 business days. Expedited review is available for urgent cases and must be completed within 72 hours.

What if StrataGraft is not on Aetna's formulary? StrataGraft is billed as a medical benefit using HCPCS code J7353, not through pharmacy formularies. Ensure your burn center bills correctly through medical benefits.

Can I request an expedited appeal in Ohio? Yes, expedited appeals are available when delay could seriously jeopardize your health. Both Aetna and Ohio's external review process offer expedited options with 72-hour decision timelines.

Does step therapy apply to StrataGraft? Step therapy requirements vary by plan. Document any contraindications to standard treatments or previous failures to support exception requests.

What happens if Ohio external review upholds the denial? IRO decisions are binding, but you retain the right to seek other remedies such as regulatory complaints or legal action if appropriate.

How much will StrataGraft cost with Aetna coverage? Out-of-pocket costs depend on your specific plan's deductible and coinsurance. StrataGraft is billed as a medical procedure, so expect costs similar to other surgical treatments.

Cost Considerations

StrataGraft is an institutional product billed during surgical procedures. Your costs will depend on:

  • Medical deductible: Applied before coinsurance kicks in
  • Coinsurance percentage: Your share of approved costs
  • Out-of-network penalties: If burn center isn't in Aetna's network
  • Facility fees: Separate charges for surgical suite and hospitalization

Contact Aetna member services to verify your specific benefits and get cost estimates before treatment.

This article provides general guidance on insurance coverage processes and should not be considered medical or legal advice. Coverage decisions depend on individual medical circumstances and specific insurance plan terms. For personalized assistance with complex denials, Counterforce Health specializes in turning insurance denials into successful appeals using evidence-based strategies tailored to each payer's requirements.

Sources & Further Reading

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