How Long Does It Take to Get Crysvita (burosumab) Approved by Aetna CVS Health in California? Complete Timeline Guide

Quick Answer: Crysvita Approval Timeline with Aetna CVS Health in California

Standard approval takes 30-45 days through CVS Specialty Pharmacy's prior authorization process. Expedited review (72 hours) is available if delays would jeopardize your health. California residents have strong appeal rights through the DMHC Independent Medical Review process, with a 55.3% success rate for overturning medical necessity denials. Start by having your endocrinologist submit genetic testing results (PHEX mutation) or elevated FGF23 levels (>110 pg/mL), plus documentation of failed conventional therapy.

First step today: Contact your specialist to gather lab results and therapy failure records, then submit the PA request via Aetna's provider portal or fax (866) 249-6155.

Table of Contents

1. What Affects Your Approval Timeline
2. Pre-Submission Preparation (0-2 Days)
3. Submission to Initial Review (1-5 Days)
4. Additional Information Requests (1-7 Days)
5. Decision Window & Outcomes
6. If Denied: California Appeal Process
7. Renewal Cycles & Reauthorization
8. Timeline Visual & Milestones
9. Time-Saving Tips

What Affects Your Approval Timeline

Several factors influence how quickly Aetna CVS Health processes your Crysvita (burosumab) prior authorization in California:

Benefit Type: Medical benefit drugs like Crysvita typically require more extensive clinical review than standard pharmacy medications, extending timelines to 30-45 days versus 5-15 days for routine prescriptions.

Documentation Completeness: Complete submissions with genetic testing results, biochemical confirmation, and detailed therapy failure records process faster. Missing documentation can add 7-14 days for additional information requests.

Clinical Complexity: X-linked hypophosphatemia (XLH) and tumor-induced osteomalacia (TIO) are rare conditions requiring specialist review. Cases with clear diagnostic criteria and established treatment failures move through faster than borderline presentations.

Formulary Status: Crysvita requires prior authorization on most Aetna plans and may be subject to step therapy requirements, meaning you must try conventional phosphate and active vitamin D therapy first.

Pre-Submission Preparation (0-2 Days)

Essential Documentation Checklist:

• Genetic Testing: PHEX gene mutation results for XLH diagnosis
• Laboratory Results (within 90 days):
  • Fasting serum phosphorus (≤2.5 mg/dL for adults)
  • Intact FGF23 levels (>110 pg/mL)
  • Normal serum calcium and PTH
  • 25-hydroxyvitamin D levels
• Prior Therapy Documentation: Records showing ≥3 months of oral phosphate plus calcitriol with persistent hypophosphatemia
• Clinical Evidence: Radiographic evidence of rickets/osteomalacia, fracture history
• ICD-10 Codes: E83.31 (X-linked hypophosphatemia) or appropriate TIO code

Prescriber Requirements: Must be an endocrinologist, nephrologist, rheumatologist, or orthopedist with experience treating metabolic bone diseases.

Tip: Counterforce Health helps patients and clinicians prepare comprehensive prior authorization submissions by identifying denial patterns and crafting evidence-backed appeals aligned to payer-specific criteria.

Submission to Initial Review (1-5 Days)

Submission Methods:

• Aetna Provider Portal: Fastest option with real-time status tracking
• Fax: (866) 249-6155 for CVS Specialty prior authorizations
• Phone: (866) 752-7021 for urgent submissions

California State Requirements: Health plans must acknowledge receipt within 5 business days and provide estimated decision timelines under California's timely access regulations.

Initial Review Process: CVS Specialty's clinical team reviews submissions for:

• Appropriate ICD-10 diagnosis coding
• Specialist prescriber credentials
• Complete laboratory documentation
• Evidence of conventional therapy failure

What Reviewers Check First:

1. Confirmed XLH or TIO diagnosis
2. Age appropriateness (≥6 months for XLH)
3. Absence of contraindications (severe renal impairment)
4. No concurrent phosphate or active vitamin D therapy

Additional Information Requests (1-7 Days)

Common requests for additional documentation include:

Missing Laboratory Values: Reviewers may request complete metabolic panels, urinalysis, or kidney function tests if not included in initial submission.

Therapy Failure Documentation: Detailed records showing specific phosphate and calcitriol doses tried, duration of therapy, and persistent biochemical abnormalities.

Clinical Justification: Medical necessity letter from prescribing specialist explaining why conventional therapy is inadequate.

Response Strategy: Submit requested information within 24-48 hours via the same portal or fax line to avoid delays. Include a cover sheet referencing the original PA request number.

Decision Window & Outcomes

Decision Type	Timeline	Approval Rate	Next Steps
Standard Review	30-45 days	~75% for complete submissions	CVS Specialty coordinates delivery
Expedited Review	72 hours	Similar to standard	Requires clinical urgency documentation
Denial	Same timeline	~25% initial denials	Internal appeal within 180 days

Reading Your Approval Letter: Look for specific authorization details including:

• Approved dosing regimen (typically 0.8 mg/kg every 2 weeks)
• Duration of authorization (usually 12 months)
• Site of care restrictions (office-based administration)
• Required monitoring parameters

Partial Approvals: Some cases receive approval for reduced quantities or modified dosing schedules, requiring clinical justification for standard protocols.

If Denied: California Appeal Process

California residents have exceptionally strong appeal rights through the Department of Managed Health Care (DMHC).

Internal Appeal (First Level):

• Deadline: 180 days from denial notice
• Timeline: 30 days for plan decision (expedited: 72 hours)
• Submission: Via Aetna member portal or written request

Independent Medical Review (External Appeal):

• When to File: After internal appeal denial or if plan doesn't respond in 30 days
• Success Rate: 55.3% overturn rate for medical necessity denials
• Timeline: 30 days standard, 3-7 days expedited
• Cost: Free to members
• Contact: DMHC Help Center at (888) 466-2219

Note: California's IMR process is binding on health plans and cannot be appealed by either party. Independent physician experts in the relevant specialty review all medical records.

Required Appeal Documentation:

• Original denial letter
• Complete medical records
• Specialist clinical summary
• Scientific literature supporting Crysvita use
• Genetic testing results
• Evidence of conventional therapy failure

Appeals through Counterforce Health's platform can help identify specific denial reasons and craft targeted rebuttals using payer-specific language and evidence requirements.

Renewal Cycles & Reauthorization

Initial Authorization: Typically approved for 12 months with specific monitoring requirements.

Reauthorization Requirements:

• Demonstration of clinical benefit (improved serum phosphorus levels)
• Radiographic evidence of healing fractures or reduced bone deformities
• Continued appropriate specialist oversight
• Updated laboratory values within 90 days

Renewal Timeline: Submit reauthorization requests 30-45 days before expiration to avoid treatment interruptions.

What Speeds Renewals:

• Consistent clinical improvement documentation
• No safety concerns or adverse events
• Maintained specialist care relationship
• Complete monitoring lab results

Timeline Visual & Milestones

Day 0-2: Gather Documentation
    ↓
Day 1-5: Submit PA Request
    ↓
Day 5-15: Initial Clinical Review
    ↓
Day 15-22: Additional Info Request (if needed)
    ↓
Day 30-45: Final Decision
    ↓
Day 46+: Appeal Process (if denied)

Key Milestones:

• Week 1: Submission acknowledgment
• Week 2-3: Clinical review in progress
• Week 4-6: Decision notification
• Week 7+: Appeal window opens (if needed)

Time-Saving Tips

Portal Optimization: Use Aetna's provider portal for real-time status updates and faster document submission compared to fax or mail.

Bundled Evidence Strategy: Submit all required documentation in a single, well-organized package rather than piecemeal submissions.

Direct Specialty Routing: Ensure submissions go directly to CVS Specialty rather than general Aetna review queues by using correct forms and contact numbers.

Peer-to-Peer Review: Request direct physician-to-physician discussion for complex cases or borderline approvals.

Expedited Processing: For patients with progressive skeletal deformities or fractures, request expedited review with supporting clinical documentation of urgency.

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Frequently Asked Questions

How long does Aetna CVS Health prior authorization take for Crysvita in California? Standard review takes 30-45 days, with expedited review available in 72 hours for urgent medical situations.

What if Crysvita is not on my Aetna formulary? Request a formulary exception with medical necessity documentation. California law requires timely review of exception requests.

Can I request an expedited appeal in California? Yes, both internal appeals and DMHC Independent Medical Review offer expedited options (72 hours and 3-7 days respectively) for urgent situations.

What documentation is required for XLH diagnosis? PHEX gene mutation testing or elevated FGF23 levels (>110 pg/mL), plus biochemical evidence of hypophosphatemia and failed conventional therapy.

Does step therapy apply if I've tried phosphate therapy outside California? Yes, documented therapy failures from other states are typically accepted if properly documented with specific drugs, doses, and duration.

What happens if my appeal is denied? California residents can request Independent Medical Review through the DMHC, which has a 55.3% success rate for overturning medical necessity denials.

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Sources & Further Reading

• DMHC Help Center - California insurance appeals and IMR process
• CVS Specialty Pharmacy - Prior authorization forms and contact information
• Aetna Provider Portal - Real-time PA status and submission tools
• Crysvita Prescribing Information - FDA-approved dosing and monitoring guidelines
• XLH Link HCP - Clinical diagnostic criteria and genetic testing resources

Disclaimer: This information is for educational purposes only and does not constitute medical advice. Always consult with your healthcare provider and insurance plan for specific coverage decisions. Coverage policies may change, and individual circumstances vary. For personalized assistance with prior authorizations and appeals, consider consulting with healthcare coverage specialists.

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