Getting StrataGraft Covered by Humana in Florida: Complete Prior Authorization and Appeals Guide
Quick Answer: Your Path to StrataGraft Coverage
StrataGraft requires prior authorization through Humana's Medicare Part B medical benefit (not pharmacy) for deep partial-thickness thermal burns in adults. Submit via Humana's provider portal with burn assessment photos, failed therapy documentation, and surgical rationale within 65 days of any denial. Standard decisions take 7-30 days; expedited reviews for urgent burns get 72-hour responses. If denied, file internal appeal within 65 days, then external review through Florida's Independent Review Organization.
First step today: Verify your Humana plan covers Part B medical benefits and gather clinical photos plus prior treatment records.
Table of Contents
- Coverage at a Glance
- Before You Start: Verify Your Coverage
- Gather What You Need
- Submit Your Prior Authorization Request
- Follow-Up and Timelines
- Common Denial Reasons and How to Fix Them
- Appeals Process in Florida
- When to Escalate
- FAQ
Coverage at a Glance
| Requirement | What It Means | Where to Find It | Source |
|---|---|---|---|
| Prior Auth Required | Yes, for Medicare Part B medical benefit | Humana Provider Portal | Humana PA Lists |
| Billing Code | HCPCS Q5123 (facility administration) | FDA labeling and CMS guidelines | FDA Approval |
| Diagnosis Requirement | Deep partial-thickness thermal burns, adults | ICD-10 burn codes (T20-T25 series) | FDA Labeling |
| Site of Care | Hospital outpatient/burn center | Medical benefit, not pharmacy | Humana Medical Coverage |
| Appeal Deadline | 65 days from denial notice | Florida follows Medicare timelines | Medicare Appeals |
Before You Start: Verify Your Coverage
Check Your Humana Plan Type
StrataGraft is covered under Medicare Part B medical benefits, not pharmacy benefits. Verify you have:
- Humana Medicare Advantage (MAPD) with Part B coverage
- Original Medicare with Humana supplement (Medigap)
- Humana Medicare-Medicaid dual special needs plan
Note: StrataGraft is not found on Humana's Part D formularies because it's a medical device administered in facilities, not a prescription drug.
Confirm In-Network Status
Treatment must occur at an in-network hospital or burn center. Call Humana member services at 1-866-488-5995 to verify your facility is in-network before scheduling surgery.
Gather What You Need
Essential Documentation Checklist
Clinical Evidence:
- Burn depth assessment confirming deep partial-thickness with intact dermis
- Clinical photographs from multiple angles showing burn characteristics
- Total body surface area (TBSA) calculations using rule of nines
- Wound measurements in cm² (StrataGraft approved for sites up to 2000 cm²)
Medical History:
- Documentation of failed conventional wound care attempts
- Prior therapy timeline with specific dates and outcomes
- Contraindications to standard autografting (limited donor sites, comorbidities)
- Relevant ICD-10 codes (T20-T25 series for anatomical burns, T31.x for TBSA extent)
Surgical Planning:
- Burn specialist consultation notes
- Surgical plan detailing why autografting is suboptimal
- Operating room scheduling confirmation
- Post-operative care protocol
Submit Your Prior Authorization Request
Submission Methods
Preferred Method - Online Portal:
- Access Humana Provider Portal
- Use Prior Authorization Search Tool to locate StrataGraft/Q5123 requirements
- Submit complete documentation package
- Track submission status in real-time
Alternative Methods:
- Fax: 888-447-3430 or 800-594-5309
- Phone: 866-461-7273 (providers)
Required Information for Submission
- Member ID and demographics
- Provider NPI and contact information
- HCPCS code Q5123 with appropriate modifiers
- Primary diagnosis with ICD-10 codes
- Clinical justification letter from burn specialist
- Supporting medical records and imaging
Tip: Submit during business hours Monday-Friday for fastest processing. Include all documentation in the initial submission to avoid delays from additional information requests.
Follow-Up and Timelines
Expected Response Times
| Request Type | Standard Timeline | Expedited Timeline |
|---|---|---|
| Pre-Service Authorization | 7-30 days | 72 hours |
| Post-Service Payment | 60 days | 72 hours |
| Additional Information | 14 days to respond | 24 hours |
When to Follow Up
- Day 3: Confirm receipt of submission
- Day 7: Check status if no response received
- Day 15: Escalate if still pending without explanation
- Day 25: Prepare appeal documentation if approaching deadline
Sample Follow-Up Script: "I'm calling to check the status of prior authorization request [reference number] for StrataGraft treatment submitted on [date]. Can you provide the current status and expected decision timeline?"
Common Denial Reasons and How to Fix Them
| Denial Reason | How to Overturn | Required Documentation |
|---|---|---|
| "Not medically necessary" | Submit burn depth assessment and autograft contraindications | Clinical photos, specialist evaluation, surgical rationale |
| "Experimental/investigational" | Provide FDA approval documentation | FDA approval letter, Phase 3 trial data |
| "Alternative treatments available" | Document why alternatives failed or are contraindicated | Prior therapy records, treatment failure notes |
| "Insufficient documentation" | Add comprehensive clinical evidence | Multi-angle photos, detailed measurements, specialist notes |
| "Wrong billing benefit" | Confirm medical benefit billing, not pharmacy | Facility administration documentation, Q5123 code verification |
Appeals Process in Florida
Internal Appeal (Level 1)
Timeline: File within 65 days of denial notice Response: 7 days standard, 72 hours expedited How to File:
- Online: Humana Appeals Portal
- Mail: Humana Grievances and Appeals, P.O. Box 14546, Lexington, KY 40512-4546
Required Components:
- Copy of original denial letter
- Member identification information
- Clinical justification for medical necessity
- Additional supporting documentation
- Physician signature and contact information
External Review (Independent Review Entity)
If Humana denies your internal appeal, you can request external review through an Independent Review Organization (IRO).
Timeline: File within 65 days of Humana's final denial Response: 30-60 days standard, 72 hours for urgent cases Cost: No charge to patient or provider
Expedited Appeals for Urgent Cases
Request expedited review if:
- Delay would seriously jeopardize life or health
- Delay would jeopardize ability to regain maximum function
- Standard timeframe would cause severe pain
Clinician Corner: Medical Necessity Letter
Your medical necessity letter should include:
Patient Assessment:
- Burn mechanism, location, and depth assessment
- TBSA calculations and wound measurements
- Photographic documentation of burn characteristics
Treatment Rationale:
- Why conventional treatments have failed or are inadequate
- Contraindications to standard autografting
- Expected outcomes with StrataGraft treatment
Clinical Evidence:
- Reference to FDA approval for deep partial-thickness burns
- Phase 3 trial data showing 96% autograft avoidance rate
- Peer-reviewed literature supporting use in similar cases
Surgical Plan:
- Detailed procedure description
- Post-operative monitoring protocol
- Long-term care expectations
When to Escalate
Florida Department of Financial Services
If you experience issues with Humana's appeal process, contact Florida's Insurance Consumer Helpline:
Phone: 1-877-MY-FL-CFO (1-877-693-5236) Website: Submit complaints online through Florida Department of Financial Services What to Include: Policy details, denial letters, appeal correspondence, timeline of events
Medicare Rights and Protections
As a Medicare beneficiary, you have additional protections:
- Right to expedited appeals for urgent medical needs
- Independent external review after internal appeals
- Protection against discrimination based on health status
At Counterforce Health, we help patients and clinicians navigate complex prior authorization processes by turning insurance denials into targeted, evidence-backed appeals. Our platform identifies denial reasons and drafts point-by-point rebuttals aligned to each plan's specific requirements, pulling the right clinical evidence and procedural details that payers expect.
FAQ
Q: How long does Humana prior authorization take for StrataGraft in Florida? A: Standard decisions take 7-30 days. Expedited reviews for urgent burn treatment get 72-hour responses when clinical urgency is documented.
Q: What if StrataGraft is denied as "experimental"? A: Submit FDA approval documentation and reference the drug's RMAT (Regenerative Medicine Advanced Therapy) designation. StrataGraft received FDA approval in 2021 for deep partial-thickness thermal burns.
Q: Can I request an expedited appeal? A: Yes, if delay would seriously jeopardize health or ability to regain function. Include clinical justification for urgency in your appeal request.
Q: Does step therapy apply to StrataGraft? A: Typically yes - you must document failure or contraindication of conventional burn treatments before StrataGraft approval.
Q: What if my burn center is out-of-network? A: Request a network adequacy exception if no in-network burn centers are available within reasonable distance. Humana may approve out-of-network coverage at in-network rates.
Q: How do I track my appeal status? A: Use Humana's online appeals portal or call member services at 1-866-488-5995 with your reference number.
From Our Advocates
"We've seen StrataGraft appeals succeed most often when providers submit comprehensive burn assessments with clear photographic evidence and detailed explanations of why standard autografting poses additional risks. The key is demonstrating that StrataGraft isn't just an alternative - it's the most appropriate treatment for the specific clinical situation."
Sources & Further Reading
- Humana Prior Authorization Lists
- StrataGraft FDA Approval Letter
- Medicare Appeals Process
- Humana Medical Coverage Policies
- Florida Department of Financial Services
Disclaimer: This guide provides general information about insurance coverage and appeal processes. It is not medical advice, legal advice, or a guarantee of coverage. Always consult with your healthcare provider about treatment decisions and verify current policy details with your insurer. Coverage policies and procedures may change; confirm current requirements with Humana and Florida regulatory authorities.
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