By Counterforce Health Team in Crysvita (burosumab) —

How to Get Crysvita (Burosumab) Covered by Humana in Illinois: Appeal Templates and Approval Guide

Quick Answer: Getting Crysvita (Burosumab) Approved by Humana in Illinois

Prior authorization is required. Humana requires genetic confirmation of X-linked hypophosphatemia (XLH) or documented tumor-induced osteomalacia (TIO), evidence of failed conventional therapy, and specialist oversight. If denied, you have 65 days to appeal internally, then 4 months for Illinois external review. Start today: Request your denial letter details, gather genetic testing and phosphate lab results, and have your endocrinologist submit comprehensive medical necessity documentation through Humana's provider portal.

Table of Contents

Understanding Your Denial Letter

When Humana denies Crysvita (burosumab), the reason typically falls into these categories:

Common Denial Codes:

  • Medical necessity not established - Missing XLH genetic confirmation or biochemical evidence
  • Step therapy required - Must try conventional phosphate/vitamin D therapy first
  • Non-formulary - Drug not on Humana's preferred list
  • Quantity limits exceeded - Dose exceeds policy maximums (90mg every 2-4 weeks)
  • Site of care restriction - May require specialty pharmacy or infusion center
Tip: Your denial letter includes specific codes and deadlines. Keep the original—you'll need exact wording for appeals.

Fixable Issues Before Appealing

Before filing a formal appeal, check if these common issues can be resolved quickly:

Missing Documentation

  • Genetic testing results confirming PHEX gene mutation
  • Serum phosphorus levels showing chronic hypophosphatemia
  • Prior therapy records documenting phosphate/vitamin D failures or intolerance
  • Specialist consultation from endocrinologist or metabolic bone disease expert

Coding Issues

  • Diagnosis code: Ensure E83.31 (X-linked hypophosphatemia) is used
  • Drug codes: Verify NDC numbers match Humana's system
  • Site of care: Confirm administration location meets policy requirements

Humana's Prior Authorization Requirements

Based on Humana's 2024-2025 formulary policies, Crysvita requires these criteria:

Requirement XLH Patients TIO Patients
Diagnosis Confirmation PHEX mutation OR elevated FGF23 FGF23-mediated hypophosphatemia with unresectable tumor
Age Requirement ≥6 months No specific age limit
Specialist Oversight Endocrinologist, nephrologist, or geneticist Endocrinologist or oncologist
Prior Therapy Failed/intolerant to phosphate + active vitamin D Documented medical necessity
Dose Limits Pediatric: 90mg/2 weeks; Adult: 90mg/4 weeks Per FDA labeling
Exclusions Cannot use with oral phosphate/vitamin D Cannot use with oral phosphate/vitamin D

Step-by-Step Appeal Process

Step 1: Internal Appeal (Days 1-65)

Timeline: Must file within 65 days of denial notice How to submit: Humana member portal or fax (verify current number)

Required documents:

  • Completed appeal form
  • Medical necessity letter from prescriber
  • Genetic testing results
  • Lab values (serum phosphorus, FGF23)
  • Prior therapy documentation
  • Clinical notes showing symptoms/functional impairment

Step 2: Peer-to-Peer Review (Optional)

Your prescriber can request a direct conversation with Humana's medical director. This often resolves complex cases faster than written appeals.

To schedule: Contact number provided in denial letter (typically within 5 business days)

Step 3: External Review (If Internal Appeal Fails)

Timeline: 4 months from internal appeal denial Authority: Illinois Department of Insurance Cost: Free to patients Decision timeline: 45 days (72 hours if expedited)

Medical Necessity Letter Template

Adapt this template with your specific clinical details:

[Provider Letterhead] Date: [Current Date] Patient: [Full Name] DOB: [Date] Humana ID: [Member ID]

RE: Appeal for Crysvita® (Burosumab-twza) - Medical Necessity

Dear Appeals Reviewer,

I am writing to appeal the denial of Crysvita® for [Patient Name], who has confirmed X-linked hypophosphatemia (ICD-10: E83.31). This patient meets all FDA-approved criteria for burosumab therapy.

Clinical Justification:

  1. Confirmed Diagnosis: [Genetic test results showing PHEX mutation] OR [Elevated FGF23 levels: X ng/mL (reference <Y)]
  2. Biochemical Evidence: Chronic hypophosphatemia [X.X mg/dL, reference range X.X-X.X]
  3. Clinical Manifestations: [List specific symptoms: bone pain, fractures, growth impairment, dental issues]
  4. Prior Therapy Failure: Patient tried [phosphate supplements X mg daily + calcitriol X mcg daily] for [duration] with [specific outcomes/side effects]
  5. Specialist Oversight: Prescribed and monitored by [Name], [credentials] specializing in metabolic bone disease

Supporting Evidence:

  • FDA approval for XLH in patients ≥6 months (2018)
  • Endocrine Society Clinical Practice Guidelines support FGF23 inhibition as first-line therapy
  • Burosumab mechanism targets underlying FGF23 excess, unlike symptomatic phosphate replacement

Proposed Monitoring:

  • Serum phosphorus every 2 weeks initially, then monthly
  • Calcium, PTH, 25(OH)D every 3 months
  • Renal ultrasound every 6 months

Enclosed: Recent labs, genetic testing, prior therapy records, clinical notes.

Please approve this medically necessary treatment.

Sincerely, [Provider Name, MD] [Contact Information]

Illinois External Review Rights

Illinois residents have strong appeal protections under the Health Carrier External Review Act.

Key Benefits:

  • Independent physician review by specialist in your condition
  • Binding decision - if approved, Humana must cover treatment
  • No cost to patients
  • Fast timeline - 45 days maximum, 72 hours if expedited

How to File:

  1. Download forms from Illinois Department of Insurance
  2. Submit within 4 months of internal appeal denial
  3. Include all medical records and denial letters

Contact for Help:

  • Illinois Department of Insurance: (217) 782-4515
  • Attorney General Health Care Helpline: 1-877-305-5145

Cost Support Options

Even with insurance approval, Crysvita costs can be significant. These programs may help:

Manufacturer Support:

  • Kyowa Kirin Cares - Copay assistance and patient support
  • Financial assistance for eligible patients

Foundation Grants:

  • Patient Advocate Foundation
  • National Organization for Rare Disorders (NORD)
  • HealthWell Foundation

Common Questions

How long does Humana prior authorization take? Standard decisions: 14 days. Expedited (if delay would harm health): 72 hours. Appeals: 30 days for internal, 45 days for external review.

What if Crysvita isn't on Humana's formulary? File a formulary exception request with medical necessity documentation. Your prescriber must explain why formulary alternatives are inappropriate.

Can I get expedited approval? Yes, if delay would "seriously jeopardize" your health or ability to regain maximum function. Your doctor must certify the urgency.

Does step therapy apply if I failed phosphate therapy in another state? Yes, document prior failures regardless of location. Include pharmacy records, lab results, and clinical notes showing inadequate response or intolerance.

What counts as "failed conventional therapy"? Typically 3-6 months of adequate-dose phosphate supplements plus active vitamin D (calcitriol or paricalcitol) with documented poor response, side effects, or contraindications like nephrocalcinosis.

When to Escalate

If appeals fail or you face procedural violations:

File Complaints With:

Red Flags Requiring Escalation:

  • Missed deadlines by Humana
  • Requests for already-submitted documentation
  • Denial without medical review
  • Failure to provide required appeal forms

About Counterforce Health

Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into successful appeals. The platform analyzes denial letters, identifies specific policy requirements, and generates evidence-backed appeal letters that address payers' exact criteria. For complex cases like Crysvita approvals, Counterforce Health streamlines the documentation process and tracks critical deadlines.

Sources & Further Reading

This guide provides educational information about insurance appeals and should not be considered medical advice. Always consult your healthcare provider about treatment decisions and follow your specific insurance plan's procedures. For personalized help with appeals, consider consulting Counterforce Health or contacting Illinois consumer assistance programs.

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