By Counterforce Health Team in Signifor / Signifor LAR (pasireotide) —

How Long Does It Take to Get Signifor LAR (Pasireotide) Approved by Humana in New York? Timeline & Appeal Process

Answer Box: Getting Signifor LAR Covered by Humana in New York

Timeline: Humana Medicare Advantage must decide on Signifor LAR (pasireotide) prior authorization within 7 calendar days (standard) or 72 hours (expedited) starting January 2026. Currently, most electronic submissions get responses within one business day.

Fastest path: Submit complete documentation through Humana's provider portal with biochemical testing (elevated UFC for Cushing's, abnormal IGF-1 for acromegaly), specialist prescriber attestation, and prior therapy history. If denied, New York residents can file external appeals through the NY Department of Financial Services within 4 months.

Start today: Gather your diagnosis codes, lab results, and documentation of failed first-line therapies—these are the most common missing pieces that delay approval.

Table of Contents

  1. What Affects Signifor LAR Approval Timing
  2. Pre-Submission Preparation (0-2 Days)
  3. Submission to Initial Review (1-7 Days)
  4. Additional Information Requests (1-7 Days)
  5. Decision Window & Outcomes
  6. If Denied: Appeal Timelines
  7. Renewal Cycles
  8. Timeline Visual & Milestones
  9. Time-Saving Tips
  10. Common Denial Reasons & Solutions
  11. New York-Specific Appeal Rights
  12. FAQ

What Affects Signifor LAR Approval Timing

Several factors determine how quickly Humana approves Signifor LAR (pasireotide) in New York:

Benefit Type & Plan: Medicare Advantage Part D plans have stricter federal timelines than commercial plans. Humana Medicare must respond to prior authorization requests within 7 days by 2026, though most electronic submissions already get faster turnaround.

Clinical Complexity: Signifor LAR requires extensive documentation because it treats rare conditions (Cushing's disease, acromegaly) and costs over $20,000 per monthly injection. Reviewers need:

  • Biochemical confirmation (24-hour urinary free cortisol for Cushing's, IGF-1 for acromegaly)
  • Evidence of surgical ineligibility or failure
  • Documentation of first-generation somatostatin analog failure (for acromegaly)
  • Board-certified endocrinologist prescription

Documentation Completeness: According to Humana's prior authorization policies, incomplete submissions trigger information requests that add 3-7 days to the process.

Note: Humana processes over 85% of complete electronic prior authorization requests within one business day as of 2025, well ahead of federal requirements.

Pre-Submission Preparation (0-2 Days)

Essential Documentation Checklist

For Cushing's Disease:

  • Elevated 24-hour urinary free cortisol (UFC) results
  • Documentation that surgery is not an option or was not curative
  • ICD-10 code: E24.0 (Pituitary-dependent Cushing's disease)
  • Prescriber: Board-certified endocrinologist

For Acromegaly:

  • Abnormal IGF-1 levels
  • Evidence of inadequate surgical response or surgical ineligibility
  • Documentation of failure/intolerance to octreotide LAR or lanreotide
  • ICD-10 code: E22.0 (Acromegaly and pituitary gigantism)
  • Prescriber: Board-certified endocrinologist

Universal Requirements:

  • Complete patient demographics and Humana member ID
  • Dosing within FDA limits (40 mg every 4 weeks for Cushing's, up to 60 mg for acromegaly)
  • Specialty pharmacy designation confirmation

Verification Steps

Call Humana at 866-488-5995 (providers) or 866-773-5959 (members) to confirm:

  1. Current formulary status and tier placement
  2. Specialty pharmacy network requirements
  3. Any recent policy updates

Submission to Initial Review (1-7 Days)

Submission Methods & Timelines

Electronic Portal (Fastest): Humana Provider Portal

  • Expected response: 1 business day for complete submissions
  • Automatic tracking and status updates
  • Preferred method for specialty medications

Fax: 800-594-5309

  • Response time: Up to 7 calendar days
  • Higher risk of documentation requests

Phone: 866-488-5995 (providers only)

  • For urgent/expedited requests
  • Immediate confirmation of receipt

What Reviewers Check First

Humana's initial review focuses on:

  1. Medical necessity criteria alignment with published policies
  2. Prescriber credentials (board certification in endocrinology)
  3. Biochemical evidence of active disease
  4. Prior therapy documentation (surgery, alternative medications)
  5. Dosing compliance with FDA-approved ranges

Additional Information Requests (1-7 Days)

If Humana requests additional information, respond immediately to avoid delays. Common requests include:

Missing Lab Values:

  • Specific UFC collection dates and methodology
  • IGF-1 age/sex-adjusted reference ranges
  • Growth hormone suppression test results (for acromegaly)

Prescriber Documentation:

  • Board certification verification
  • Detailed clinical notes supporting diagnosis
  • Treatment rationale letter

Prior Therapy Details:

  • Exact dates of surgical procedures
  • Medication trial durations and outcomes
  • Adverse event documentation
Tip: Submit comprehensive documentation upfront rather than waiting for requests. This single step can reduce approval time from 7 days to 24 hours.

Decision Window & Outcomes

Typical Approval Scenarios

Immediate Approval (24-48 hours): Complete electronic submission with all required documentation from board-certified endocrinologist.

Conditional Approval (3-5 days): Approval with quantity limits, step therapy requirements, or periodic monitoring mandates.

Denial (7 days maximum): Usually due to insufficient biochemical evidence, lack of specialist involvement, or failure to document prior therapy attempts.

Reading Your Approval Letter

Approved requests will specify:

  • Authorized dosing and frequency
  • Approved duration (typically 12 months)
  • Required specialty pharmacy
  • Monitoring requirements
  • Renewal timeline

If Denied: Appeal Timelines

Humana Internal Appeals

Standard Appeal: 65 calendar days from denial notice to file

  • Decision deadline: 30 days for medical services, 7 days for drugs
  • Submit via Humana member portal or mail

Expedited Appeal: Available if delay would seriously jeopardize health

  • Decision deadline: 72 hours
  • Required: Physician attestation of urgency

Documentation for Appeals

Include in your appeal:

  • Original denial letter
  • Additional clinical evidence addressing denial reasons
  • Peer-reviewed literature supporting off-label use (if applicable)
  • Specialist letter emphasizing medical necessity

Renewal Cycles

Signifor LAR approvals typically last 12 months. Begin renewal process 30-60 days before expiration:

Required for Renewal:

  • Updated biochemical markers showing treatment response
  • Continued specialist oversight
  • Documentation of treatment tolerance
  • Any dose adjustments with clinical justification

Expedited Renewals: Patients with stable disease and good treatment response often get faster renewal approvals (1-3 days vs. 7 days for new requests).

Timeline Visual & Milestones

Milestone Timeline Key Actions
Preparation 0-2 days Gather labs, specialist letters, prior therapy records
Submission Day 1 Submit via electronic portal with complete documentation
Initial Review 1-7 days Humana reviews medical necessity criteria
Additional Info +1-7 days Respond immediately to any documentation requests
Decision 7 days max Approval, denial, or conditional approval issued
Appeal (if needed) 65 days to file Internal appeal with additional evidence
External Appeal +4 months New York State Department of Financial Services

Time-Saving Tips

  1. Use Electronic Submission: Humana's provider portal processes 95% of complete requests within one business day.
  2. Bundle All Evidence: Submit comprehensive documentation upfront rather than responding to multiple information requests.
  3. Specialty Routing: Ensure requests go directly to Humana's specialty pharmacy team by clearly marking "specialty medication" on submissions.
  4. Peer-to-Peer Option: For complex cases, request a peer-to-peer review with Humana's medical director—this can resolve denials without formal appeals.
  5. Track Deadlines: Use Humana's online portal to monitor request status and avoid missed deadlines.

When patients face insurance barriers, platforms like Counterforce Health can help by automatically generating evidence-backed appeals that address specific denial reasons with targeted clinical documentation and payer-specific formatting requirements.

Common Denial Reasons & Solutions

Denial Reason Solution Required Documentation
Insufficient biochemical evidence Submit complete hormone testing 24-hour UFC (Cushing's), IGF-1 with reference ranges (acromegaly)
Non-specialist prescriber Transfer to endocrinologist Board certification verification, specialist consultation notes
Lack of prior therapy documentation Provide detailed treatment history Surgery reports, medication trial records with dates/outcomes
Dosing outside FDA limits Adjust dose or provide clinical justification Literature supporting higher doses, specialist rationale letter
Missing step therapy Document first-line therapy failure Octreotide/lanreotide trial records (for acromegaly cases)

New York-Specific Appeal Rights

New York residents have additional protection through the state's external appeal system:

External Appeal Process

Eligibility: Available after completing Humana's internal appeal process or if Humana waives internal review.

Timeline: Must file within 4 months of final adverse determination.

Cost: $25 fee (waived for Medicaid enrollees or financial hardship cases).

Expedited Review: Available for urgent cases—decision within 72 hours (24 hours for non-formulary drugs).

Filing an External Appeal

  1. Complete the external appeal application
  2. Include physician attestation form for rare disease drugs
  3. Submit all supporting clinical documentation
  4. Pay required fee (if applicable)

Key Advantage: External appeal decisions are binding on Humana and often overturn denials based on medical literature review by independent specialists.

For assistance with appeals, New York residents can contact Community Health Advocates at 888-614-5400 for free counseling and support.

FAQ

Q: How long does Humana prior authorization take for Signifor LAR in New York? A: Currently 1 business day for complete electronic submissions; 7 calendar days maximum starting January 2026. Expedited requests get 72-hour decisions.

Q: What if Signifor LAR is non-formulary on my Humana plan? A: Request a formulary exception with medical necessity documentation. New York allows external appeals for non-formulary drug denials with 24-hour expedited review.

Q: Can I get temporary coverage while waiting for approval? A: Yes, Humana may provide up to 31 days of coverage during transitions or emergency situations while prior authorization is pending.

Q: Does step therapy apply if I failed similar drugs outside New York? A: Yes, document all prior therapy attempts regardless of location. Include dates, doses, duration, and reasons for discontinuation.

Q: Who can prescribe Signifor LAR for Humana coverage? A: Typically requires a board-certified endocrinologist. Some plans may accept other specialists with documented expertise in pituitary disorders.

Q: What's the difference between Signifor and Signifor LAR coverage? A: Signifor LAR (long-acting) is preferred for both Cushing's disease and acromegaly. Regular Signifor (subcutaneous) is typically limited to Cushing's disease when LAR is not appropriate.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage policies and timelines may change. Always verify current requirements with Humana directly and consult your healthcare provider for medical decisions. For personalized assistance with complex prior authorization requirements and appeals, Counterforce Health provides specialized support for patients and clinicians navigating insurance coverage for specialty medications.

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