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

Getting StrataGraft Covered by Blue Cross Blue Shield in Washington: Prior Authorization Guide, Appeals Process & Alternative Options

Answer Box: Getting StrataGraft Covered by BCBS Washington

StrataGraft requires prior authorization from Blue Cross Blue Shield in Washington. The fastest path: 1) Have your burn center submit PA documentation showing deep partial-thickness burns with intact dermis and contraindications to autografting, 2) Include clinical photos and failed standard therapy records, 3) If denied, file internal appeal within 60 days, then external IRO review within 21 days. Start by calling BCBS member services at the number on your card to confirm current PA requirements and forms.

Table of Contents

Coverage Requirements at a Glance

Requirement What It Means Where to Find It
Prior Authorization BCBS approval needed before treatment Member services or provider portal
Medical Necessity Deep partial-thickness burns with intact dermis FDA labeling requirements
Contraindications to Autograft Must document why standard grafting isn't suitable Clinical notes from burn specialist
Facility Billing Required Cannot be billed through pharmacy benefit Hospital/burn center billing department
Appeals Deadline 60 days for internal, 21 days for external review Washington Insurance Commissioner

When StrataGraft Alternatives Make Sense

Before pursuing StrataGraft approval, it's important to understand when alternative burn treatments might be more appropriate or accessible through your BCBS Washington plan.

Clinical Scenarios Where Alternatives Apply:

  • Superficial or first-degree burns (StrataGraft isn't indicated)
  • Small burn areas where conservative management is sufficient
  • When autografting donor sites are readily available and patient is a good surgical candidate
  • Budget constraints where proven alternatives offer similar outcomes

Insurance Coverage Considerations: Most BCBS Washington plans cover standard burn treatments like split-thickness autografts, temporary biologic dressings, and wound care supplies without the extensive prior authorization requirements needed for StrataGraft. These alternatives often have established coverage pathways and predictable approval timelines.

Typical Formulary Alternatives for Deep Partial-Thickness Burns

Autologous Skin Grafts (Gold Standard)

Split-thickness skin grafts remain the most widely covered option for deep partial-thickness burns. BCBS Washington typically covers these procedures when performed by in-network burn specialists or plastic surgeons.

Temporary Biologic Dressings

  • Cadaver allografts: Human donor skin used as temporary coverage
  • Xenografts: Porcine (pig) skin products for temporary wound protection
  • Synthetic substitutes: Products like Integra, Dermagraft, and Apligraf

Advanced Wound Care Products

BCBS Washington often covers specialized dressings, growth factors, and wound care protocols that can promote healing in appropriate burn cases without requiring surgical intervention.

Note: Coverage for these alternatives varies by specific BCBS Washington plan. Premera Blue Cross, Regence BlueShield, and other Washington Blues may have different formulary tiers and approval processes.

Pros and Cons of Alternative Options

Autologous Skin Grafts

Pros: Well-established coverage, proven outcomes, widely available Cons: Requires donor site surgery, potential for scarring at both sites, longer recovery

Temporary Biologics

Pros: Less invasive than grafting, good for wound preparation Cons: Multiple applications often needed, temporary solution only

Advanced Wound Care

Pros: Non-surgical, good for appropriate candidates Cons: Limited effectiveness for deep burns, longer healing times

Access Considerations:

  • Autografts: Available at most burn centers, typically covered
  • Biologics: May require prior authorization, limited shelf life
  • Advanced care: Often covered but requires documentation of medical necessity

Exception Strategy: Building Your Case for StrataGraft

When standard alternatives aren't suitable, building a strong exception request for StrataGraft requires specific clinical documentation.

Key Evidence to Gather:

  1. Burn characteristics: Depth assessment showing deep partial-thickness with intact dermal elements
  2. Contraindications to autografting: Limited donor sites, comorbidities, previous graft failures
  3. Failed conservative therapy: Documentation of standard wound care attempts
  4. Clinical photos: Visual evidence of burn severity and wound characteristics
  5. Specialist consultation: Notes from burn surgeon supporting StrataGraft indication

Guideline Support: Reference the FDA approval criteria for StrataGraft, which specifically addresses deep partial-thickness thermal burns in adults when autografting is clinically indicated but may be contraindicated or undesirable.

Clinician Corner: Medical necessity letters should include specific burn measurements (% TBSA), depth assessment, prior treatment timeline with outcomes, and clear rationale for why StrataGraft offers superior outcomes compared to available alternatives in this specific case.

Step-by-Step: Fastest Path to Approval

  1. Contact BCBS Member Services (Patient/Family)
    • Call the number on your insurance card
    • Ask for current StrataGraft prior authorization requirements
    • Request PA forms and submission instructions
    • Timeline: Same day
  2. Burn Center Assessment (Clinical Team)
    • Complete burn evaluation with photos
    • Document contraindications to autografting
    • Gather supporting clinical records
    • Timeline: 1-2 days
  3. Submit Prior Authorization (Provider)
    • Complete BCBS PA forms with clinical justification
    • Include all supporting documentation
    • Submit via provider portal or fax
    • Timeline: Same day submission
  4. BCBS Review Process (Insurance)
    • Initial review by utilization management
    • Possible peer-to-peer review request
    • Coverage determination issued
    • Timeline: 5-14 business days
  5. If Approved (All Parties)
    • Schedule StrataGraft application
    • Confirm facility billing procedures
    • Timeline: Based on clinical urgency
  6. If Denied (Patient/Provider)
    • Review denial letter for specific reasons
    • Prepare internal appeal within 60 days
    • Timeline: Begin immediately
  7. Appeal Process (If Needed)
    • Submit internal appeal with additional evidence
    • If denied, file external IRO review
    • Timeline: 21 days between levels

Appeals Playbook for BCBS Washington

Internal Appeal Process

Deadline: 60 calendar days from denial letter date How to File: BCBS member portal, written request, or phone Required Documents: Denial letter, additional clinical evidence, provider support letter

External Review (IRO)

Deadline: 21 calendar days after final internal denial How to File: Request through Washington Insurance Commissioner Cost: Free to consumer Decision: Binding on BCBS if overturned

Expedited Appeals

Available when delay could jeopardize health. Must provide medical documentation supporting urgency.

From Our Advocates: We've seen successful StrataGraft appeals when families worked closely with their burn center to document why standard autografting wasn't feasible—whether due to limited donor sites from extensive burns or patient comorbidities that increased surgical risk. The key was providing specific clinical rationale rather than general statements about treatment preferences.

Common Denial Reasons & How to Fix Them

Denial Reason How to Overturn
"Not medically necessary" Submit burn depth assessment, contraindications to autograft
"Experimental/investigational" Provide FDA approval documentation, clinical trial data
"Alternative treatments available" Document why alternatives failed or are contraindicated
"Insufficient documentation" Add clinical photos, specialist notes, treatment timeline
"Wrong billing code" Ensure facility billing, not pharmacy benefit submission

Switching Between Treatment Options

Coordination with Your Care Team: If StrataGraft isn't initially approved, work with your burn center to implement appropriate alternative treatments while continuing the appeals process. This ensures wound care continues without delay.

Insurance Logistics:

  • Maintain documentation of all treatments attempted
  • Keep detailed records of outcomes and any complications
  • Preserve option to resubmit StrataGraft request if alternatives fail

Provider Communication: Ensure your burn specialist understands your insurance situation and can adjust treatment plans accordingly while maintaining optimal clinical outcomes.

Re-trying for StrataGraft Later

When to Resubmit:

  • After documented failure of alternative treatments
  • If clinical condition changes (new contraindications to autografting)
  • With new supporting evidence or clinical guidelines
  • After successful external review establishing precedent

Documentation During Alternative Therapy:

  • Detailed wound healing progress (or lack thereof)
  • Any complications from alternative treatments
  • Patient tolerance and quality of life impacts
  • Objective measures like wound measurements, photos

Building Stronger Cases: Each treatment attempt provides additional clinical evidence that can strengthen future StrataGraft requests, particularly if alternatives prove inadequate for your specific situation.

Frequently Asked Questions

How long does BCBS prior authorization take in Washington? Standard PA reviews take 5-14 business days. Expedited reviews for urgent cases can be completed in 72 hours with proper medical documentation.

What if StrataGraft isn't on the formulary? StrataGraft is billed as a facility procedure, not a pharmacy benefit. Coverage is handled through medical benefits rather than drug formularies.

Can I request an expedited appeal? Yes, if delay would jeopardize your health. Provide medical documentation supporting the urgent need for treatment.

Does step therapy apply if I've failed treatments outside Washington? Medical records from other states are generally accepted if properly documented. Work with your current burn center to compile comprehensive treatment history.

What's the success rate for StrataGraft appeals in Washington? While specific statistics aren't published, Washington's external review process has helped many patients access specialty treatments after initial denials.

Can I switch insurance plans to get better StrataGraft coverage? During open enrollment periods, you can compare plans. However, pre-existing conditions and treatment timing may affect this strategy.

What if my employer plan is self-funded? Self-funded ERISA plans may not be subject to Washington state appeal processes. Contact the U.S. Department of Labor for guidance on ERISA plan appeals.

How much does StrataGraft cost without insurance? StrataGraft is an institutional product without published retail pricing. Costs vary by facility and are typically substantial, making insurance coverage crucial.

About Coverage Advocacy

Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into successful appeals. Their platform analyzes denial letters and plan policies to create targeted, evidence-backed appeals that align with each insurer's specific requirements—taking the guesswork out of complex coverage battles for treatments like StrataGraft.

For additional support with BCBS Washington appeals, Counterforce Health provides tools and expertise to help navigate the prior authorization and appeals process more effectively.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage policies change frequently. Always verify current requirements with your specific BCBS Washington plan and consult with your healthcare providers about the most appropriate treatment options for your individual situation. For personalized help with insurance appeals, contact the Washington Office of the Insurance Commissioner at 1-800-562-6900.

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