By Counterforce Health Team in Crysvita (burosumab) —

How to Get Crysvita (burosumab) Covered by Blue Cross Blue Shield in New Jersey: Prior Authorization Guide and Appeal Process

Answer Box: Getting Crysvita Covered in New Jersey

Blue Cross Blue Shield of New Jersey (Horizon BCBSNJ) requires prior authorization for Crysvita (burosumab) treatment. Success requires: (1) confirmed XLH or TIO diagnosis with genetic/biochemical testing, (2) specialist prescription from an endocrinologist, (3) documentation of failed standard therapies (oral phosphate/vitamin D), and (4) complete medical necessity packet. Submit through Horizon's prior authorization portal. If denied, New Jersey's IHCAP external review through Maximus offers strong reversal potential within 4 months of denial.

Table of Contents

  1. What This Guide Covers
  2. Before You Start: Verify Your Coverage
  3. Gather Required Documentation
  4. Submit Your Prior Authorization Request
  5. Follow-Up and Timeline Management
  6. If You Need More Information
  7. If Your Request is Denied
  8. New Jersey External Appeals Process
  9. Renewal and Re-Authorization
  10. Quick Reference Checklist

What This Guide Covers

This comprehensive guide helps patients with X-linked hypophosphatemia (XLH) or tumor-induced osteomalacia (TIO) navigate the prior authorization process for Crysvita (burosumab) with Blue Cross Blue Shield plans in New Jersey. Whether you're working with Horizon Blue Cross Blue Shield of New Jersey (the state's largest insurer with ~39% market share) or another Blue Cross affiliate, this guide provides the step-by-step process, required documentation, and appeal strategies specific to New Jersey's regulatory environment.

Crysvita is a specialty medication that typically costs $4,000-$40,000+ per vial depending on dosing requirements. Given these costs, insurance approval is essential for most patients. The good news: with proper documentation and persistence through New Jersey's robust appeals process, many patients successfully obtain coverage.

Before You Start: Verify Your Coverage

Check Your Plan Type and Formulary Status

First, confirm your specific Blue Cross Blue Shield plan type, as requirements vary:

Confirm Medical vs. Pharmacy Benefit

Crysvita is typically covered under the medical benefit (not standard pharmacy) and billed using HCPCS code J0584. This means it's usually administered in a clinical setting like an infusion center or physician's office, not picked up at a retail pharmacy.

Note: Horizon lists Crysvita on their office-administered specialty medications list, confirming medical benefit coverage.

Gather Required Documentation

Essential Clinical Documentation

Diagnosis Confirmation:

  • Genetic testing results confirming XLH mutation (for X-linked hypophosphatemia)
  • Biochemical testing: low serum phosphate, elevated FGF23, low/normal 1,25(OH)₂D
  • For TIO: imaging showing phosphaturic mesenchymal tumor that cannot be resected

ICD-10 Codes to Include:

  • XLH: E83.31 (Familial hypophosphatemia) or M90.80 (X-linked hypophosphatemia)
  • TIO: M83.8 (Other adult osteomalacia)
  • Supporting: E83.30 (Disorder of phosphorus metabolism, unspecified)

Prior Treatment History:

  • Documentation of trials with oral phosphate supplements
  • Previous use of active vitamin D analogs (calcitriol)
  • Reasons for discontinuation (ineffectiveness, intolerance, side effects)
  • Current medication list confirming discontinuation of oral phosphate/vitamin D

Specialist Requirements

Horizon BCBSNJ typically requires prescription by or consultation with:

  • Endocrinologist
  • Metabolic bone disorder specialist
  • Pediatric endocrinologist (for children)

Include consultation notes and treatment recommendations from the specialist.

Laboratory and Monitoring Plan

  • Recent serum phosphate levels
  • Alkaline phosphatase
  • Parathyroid hormone (PTH)
  • 25(OH)D and 1,25(OH)₂D levels
  • Proposed monitoring schedule during treatment

Submit Your Prior Authorization Request

Horizon BCBSNJ Submission Process

  1. Access the Portal: Use Horizon's prior authorization search tool to confirm current requirements and forms.
  2. Complete Required Forms: Submit through the provider portal or designated fax line (verify current contact information through the portal).
  3. Include Complete Documentation Package:
    • Prior authorization form
    • Clinical notes and consultation reports
    • Laboratory results
    • Genetic testing (for XLH)
    • Prior therapy documentation
    • Proposed dosing schedule

Clean Request Packet Checklist

✓ Completed PA form with all required fields
✓ ICD-10 codes clearly documented
✓ Specialist consultation notes
✓ Lab results (phosphate, FGF23, vitamin D metabolites)
✓ Prior therapy trials and outcomes
✓ Current medication list
✓ Proposed monitoring plan
✓ Dosing rationale based on patient weight

Follow-Up and Timeline Management

Standard Processing Times

  • Commercial plans: Typically 15 business days for non-urgent requests
  • Expedited/urgent: 72 hours when medical necessity is documented
  • Medicaid: Follow New Jersey Medicaid timelines (verify current requirements)

Sample Follow-Up Call Script

"Hello, I'm calling to check on the status of a prior authorization request for Crysvita submitted on [date]. The patient is [name], member ID [number], and the request reference number is [number]. Can you provide a status update and let me know if any additional information is needed?"

Document all interactions: Keep records of call dates, reference numbers, and representative names.

If You Need More Information

Common Information Requests

Medical Necessity Clarification:

  • Additional clinical notes explaining treatment rationale
  • Literature supporting Crysvita use for your specific condition
  • Specialist letter addressing specific plan criteria

Dosing Justification:

  • Weight-based dosing calculations
  • Explanation of proposed administration schedule
  • Monitoring plan during dose adjustments

Key Clinical References to Include

  • FDA prescribing information for Crysvita
  • Endocrine Society clinical practice guidelines for XLH management
  • Published studies demonstrating efficacy in your patient population

If Your Request is Denied

Common Denial Reasons and Solutions

Denial Reason Solution Strategy
Insufficient diagnosis documentation Submit genetic testing results and specialist consultation
Missing prior therapy trials Provide detailed history of phosphate/vitamin D use and outcomes
Incorrect prescriber Ensure endocrinologist or specialist involvement
Dosing concerns Include weight-based calculations and FDA label reference
Missing monitoring plan Submit detailed lab monitoring schedule

Peer-to-Peer Review Request

If initially denied, request a peer-to-peer review with a board-certified physician. Prepare to discuss:

  • Clinical rationale for Crysvita over standard therapy
  • Patient-specific factors supporting medical necessity
  • Expected outcomes and monitoring plan
  • Consequences of delayed treatment

At Counterforce Health, we help patients and providers turn insurance denials into successful appeals by analyzing denial letters, identifying specific coverage criteria, and drafting evidence-backed rebuttals. Our platform streamlines the complex prior authorization process, helping families get the specialty medications they need without the administrative burden.

New Jersey External Appeals Process

IHCAP Through Maximus

If Horizon BCBSNJ denies your internal appeals, New Jersey's Independent Health Care Appeals Program (IHCAP) provides external review through Maximus Federal Services.

Key Details:

  • Filing deadline: 4 months (180 days) from final internal denial
  • Application fee: $25 (may be waived for financial hardship)
  • Decision timeline: 45 days for standard appeals, 48 hours for expedited
  • Binding outcome: If overturned, Horizon must comply within 10 business days

How to File with IHCAP

  1. Complete internal appeals with Horizon first (unless expedited)
  2. Register at the Maximus portal
  3. Upload required documents:
    • IHCAP appeal form
    • Final denial notice from Horizon
    • Medical records supporting necessity
    • Clinical literature and guidelines
  4. Pay $25 fee (request hardship waiver if needed)
  5. Monitor portal for status updates and decision
From our advocates: We've seen strong success rates with New Jersey external appeals when patients include comprehensive clinical documentation and address the specific denial reasons point-by-point. One effective strategy is organizing the appeal around the plan's own medical policy criteria, showing how the patient meets each requirement with supporting evidence.

Success Factors for External Appeals

  • Thorough medical documentation supporting diagnosis and treatment need
  • Clinical guidelines from recognized medical societies
  • Specialist support with detailed necessity letter
  • Addressing specific denial reasons with targeted evidence
  • Timely submission well before the 180-day deadline

Renewal and Re-Authorization

Planning for Continuity

Most Crysvita authorizations require renewal every 6-12 months. Calendar renewal dates and begin the process 60-90 days early to avoid treatment interruptions.

Renewal Documentation:

  • Updated clinical response data (serum phosphate levels, symptom improvement)
  • Continued specialist oversight
  • Monitoring lab results
  • Any dose adjustments and rationale
  • Confirmation of ongoing medical necessity

Demonstrating Treatment Response

Document positive outcomes such as:

  • Improved serum phosphate levels
  • Reduced bone pain
  • Better mobility and function
  • Decreased fracture risk
  • Growth velocity improvement (in children)

Quick Reference Checklist

Before Starting

□ Verify plan type and formulary status
□ Confirm medical benefit coverage
□ Identify required specialist involvement

Documentation Gathering

□ Genetic testing results (XLH) or tumor imaging (TIO)
□ Recent lab results (phosphate, FGF23, vitamin D)
□ Prior therapy documentation
□ Specialist consultation notes
□ ICD-10 codes: E83.31, M90.80, or M83.8

Submission

□ Complete PA form through Horizon portal
□ Include all supporting documentation
□ Document submission date and reference number
□ Set follow-up reminder for 10-14 days

If Denied

□ Request peer-to-peer review
□ File internal appeal within required timeframe
□ Consider external IHCAP appeal through Maximus
□ Maintain detailed records of all interactions

Need help navigating the appeals process? Counterforce Health specializes in turning insurance denials into successful approvals by creating targeted, evidence-backed appeals that align with each plan's specific requirements.

Sources & Further Reading

Disclaimer: This guide provides general information about insurance processes and should not be considered medical or legal advice. Coverage decisions depend on individual circumstances and specific plan terms. Always consult with your healthcare provider about treatment decisions and verify current requirements with your insurance plan. For personalized assistance with appeals and prior authorizations, consider consulting with patient advocacy services or legal professionals specializing in healthcare coverage.

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