By Counterforce Health Team in Crysvita (burosumab) —

How to Get Crysvita (Burosumab) Covered by Humana in New Jersey: Complete Appeals Guide with Templates

Answer Box: Getting Crysvita (Burosumab) Covered by Humana in New Jersey

Eligibility: Humana Medicare Advantage plans in New Jersey require prior authorization for Crysvita (burosumab) for X-linked hypophosphatemia (XLH) and tumor-induced osteomalacia (TIO). Coverage typically requires genetic confirmation of XLH or elevated FGF23 levels, specialist prescription, and documented failure of conventional therapy.

Fastest path: Have your endocrinologist submit a complete prior authorization request through Humana's provider portal with genetic testing results, baseline phosphorus levels, and detailed medical necessity letter addressing Humana's specific criteria.

First step today: Contact Humana member services at 1-800-833-2364 to confirm your plan's formulary status for Crysvita and request the current prior authorization form for your specific Medicare Advantage plan.

Table of Contents

Coverage Requirements at a Glance

Requirement What It Means Where to Find It
Prior Authorization Required for all Crysvita claims Humana 2025 Medicare Prior Authorization List
Formulary Status Typically Tier 5 (specialty) Your plan's Evidence of Coverage document
Specialist Required Endocrinologist or metabolic bone disease specialist Humana coverage policy for Crysvita
Diagnosis Codes E83.31 (XLH), M83.8 (osteomalacia), E83.39 (other phosphate disorders) ICD-10 coding guidelines
HCPCS Code J0584 (injection, burosumab-twza, 1 mg) Medicare billing guidelines
Site of Care Physician office or hospital outpatient Medicare Part B coverage rules

Step-by-Step: Fastest Path to Approval

1. Verify Coverage and Benefits

Who: You or your clinic's benefits verification team
What: Call Humana at 1-800-833-2364 with your member ID
Ask for: Current formulary status, prior authorization requirements, and any quantity limits
Timeline: 15-30 minutes

2. Gather Required Documentation

Who: Your endocrinologist's office
What needed:

  • Genetic testing showing PHEX mutation (for XLH) or elevated FGF23 levels
  • Baseline fasting serum phosphorus levels (below normal range)
  • Radiographic evidence of rickets/osteomalacia
  • Documentation of conventional therapy trials (phosphate + active vitamin D)
  • Growth charts (pediatric patients) or functional assessments (adults)

3. Submit Prior Authorization Request

Who: Prescribing physician
How: Through Humana's provider portal or fax to the number listed in your plan's PA list
Include: Completed PA form, medical necessity letter, lab results, imaging reports
Timeline: Humana has 30 days for standard requests, 72 hours for expedited

4. Follow Up on Decision

Who: You or your clinic
When: If no response within 15 days (standard) or 24 hours (expedited)
Contact: Humana provider services at 1-800-448-6262
Track: Keep confirmation numbers for all submissions

5. Appeal if Denied

Who: You and your physician
Deadline: 65 days from denial notice date
How: Submit reconsideration request with additional supporting evidence
Next level: Independent Review Entity (IRE) if internal appeal fails

Clinician Corner: Medical Necessity Documentation

When preparing a medical necessity letter for Crysvita, address these key elements that Humana reviewers specifically look for:

Essential Components:

  • Confirmed diagnosis: Include genetic testing results showing PHEX mutation or clinical phenotype consistent with XLH plus elevated FGF23
  • Biochemical evidence: Document persistent hypophosphatemia with specific fasting serum phosphorus values below age-adjusted normal ranges
  • Prior therapy history: Detail previous treatment with oral phosphate and active vitamin D analogs, including doses, duration, and reasons for discontinuation
  • Clinical manifestations: Describe bone pain, growth delays, dental issues, fractures, or mobility limitations
  • Treatment goals: Specify expected outcomes such as improved growth velocity, reduced bone pain, or enhanced quality of life

Supporting Evidence to Include:

Tip: Reference Humana's specific coverage criteria in your letter. Many payers appreciate when clinicians directly address their policy requirements rather than using generic templates.

At Counterforce Health, we help clinicians and patients turn insurance denials into successful appeals by analyzing payer policies and crafting targeted, evidence-backed responses. Our platform identifies the specific denial reasons and creates point-by-point rebuttals aligned to each plan's requirements.

Common Denial Reasons & Solutions

Denial Reason How to Overturn
"Insufficient genetic confirmation" Submit PHEX mutation testing or detailed family history with affected relatives
"Concurrent use with oral phosphate" Provide treatment timeline showing discontinuation of phosphate supplements before Crysvita
"Lack of specialist evaluation" Ensure prescription comes from endocrinologist or metabolic bone disease specialist
"Missing baseline labs" Include fasting serum phosphorus, 25(OH)D, 1,25(OH)2D, PTH, and FGF23 levels
"Inadequate prior therapy documentation" Detail specific oral phosphate and calcitriol doses, duration, and side effects experienced
"Not medically necessary" Provide functional assessments, growth charts, imaging showing bone disease progression

Appeals Process for Humana Medicare Advantage in New Jersey

Important: Humana Medicare Advantage plans in New Jersey follow federal Medicare appeals rules, not New Jersey's state IHCAP system.

Level 1: Plan Reconsideration

  • Deadline: 65 days from denial notice
  • How to file: Online through Humana member portal, by phone (1-800-833-2364), or mail
  • Timeline: 30 days for standard, 72 hours for expedited
  • Include: Additional medical records, peer-reviewed studies, specialist letters

Level 2: Independent Review Entity (IRE)

  • When: After adverse Level 1 decision
  • Reviewer: Maximus (current Medicare IRE contractor)
  • Timeline: 30 days standard, 72 hours expedited
  • Cost: Free to you

Expedited Appeals

Request expedited review if waiting for standard timeline could seriously jeopardize your health. Your doctor must support the request with clinical documentation.

From our advocates: We've seen cases where patients initially denied for Crysvita succeeded on appeal by including detailed growth charts showing continued decline despite conventional therapy, along with photos documenting progressive skeletal deformities. The visual evidence, combined with specialist letters explaining the urgency of FGF23 blockade, often resonates with medical reviewers.

Cost Assistance and Patient Support

Manufacturer Support:

  • Crysvita CarePath: Patient assistance program offering copay support and prior authorization assistance
  • Income-based financial assistance for eligible patients

Foundation Resources:

  • National Organization for Rare Disorders (NORD) Patient Assistance Programs
  • HealthWell Foundation grants for rare disease treatments
  • Good Days foundation copay assistance

Medicare-Specific:

  • Medicare Part B covers Crysvita as a physician-administered drug
  • Low Income Subsidy (LIS) may reduce out-of-pocket costs for dual-eligible beneficiaries

Frequently Asked Questions

How long does Humana prior authorization take for Crysvita? Standard requests: up to 30 days. Expedited requests (when delay could harm your health): 72 hours. You can check status through Humana's provider or member portal.

What if Crysvita is not on my Humana formulary? You can request a formulary exception through the same prior authorization process. Include compelling medical necessity documentation showing why covered alternatives are inappropriate.

Can I appeal a Humana denial in New Jersey state court? No. Medicare Advantage appeals follow federal rules and ultimately go through Medicare's Administrative Law Judge system, not New Jersey state external review.

Does step therapy apply to Crysvita with Humana? Yes, most Humana policies require documentation of inadequate response to conventional therapy (oral phosphate plus active vitamin D) before approving Crysvita for adults with XLH.

What happens if I start Crysvita before approval? You may be responsible for the full cost (potentially $4,000-$40,000+ per dose). Always wait for written authorization unless it's a true emergency.

How do I request a peer-to-peer review with Humana? Your physician can request to speak directly with Humana's medical director by calling the provider line and asking for "peer-to-peer review for prior authorization denial."

Getting the right coverage for rare disease treatments like Crysvita requires persistence and detailed documentation. Counterforce Health specializes in helping patients and clinicians navigate these complex approval processes by turning denials into targeted appeals that address each payer's specific requirements.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage policies vary by plan and change frequently. Always verify current requirements with your specific Humana plan and consult with your healthcare provider for medical decisions. For official appeals assistance in New Jersey, contact the NJ Department of Banking and Insurance at 1-800-446-7467.

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