By Counterforce Health Team in Duopa (carbidopa/levodopa enteral) —

How to Get Duopa Covered by Humana in New York: Complete Prior Authorization Guide

Answer Box: To get Duopa covered by Humana in New York, you need prior authorization showing advanced Parkinson's disease with motor fluctuations despite optimized oral therapy. The fastest path: (1) Document 3+ hours daily "OFF" time with patient diaries, (2) Submit PA request through Humana's provider portal with movement disorder specialist evaluation, (3) If denied, file internal appeal within 65 days, then request New York external review through DFS. Start by gathering your medication history and "OFF" time documentation today.

Table of Contents

  1. Who Should Use This Guide
  2. Member & Plan Basics
  3. Clinical Criteria for Coverage
  4. Coding & Billing Requirements
  5. Documentation Packet
  6. Submission Process
  7. Specialty Pharmacy Routing
  8. After Submission
  9. Appeals Playbook for New York
  10. Common Denial Reasons & Solutions
  11. Cost-Saving Options
  12. Quick Reference Checklist

Who Should Use This Guide

This guide helps patients with advanced Parkinson's disease and their healthcare providers navigate Humana's prior authorization process for Duopa (carbidopa/levodopa enteral suspension) in New York. You'll find this useful if:

  • You have Humana Medicare Advantage or Part D coverage in New York
  • Your neurologist has recommended Duopa for motor fluctuations
  • You've experienced "OFF" time despite optimized oral medications
  • You need to appeal a Duopa denial from Humana

Expected outcome: With proper documentation and persistence, many patients successfully obtain Duopa coverage. Humana's PA denial rate is relatively low at ~3.5%, but denials that occur often involve documentation gaps that can be addressed through appeals.

Member & Plan Basics

Coverage Requirements

  • Active Humana coverage: Medicare Advantage or Part D plan in New York
  • Plan type: Most Humana plans require prior authorization for Duopa
  • Formulary status: Duopa is typically Tier 5 (specialty medication) with 33% coinsurance
  • Deductible: May apply depending on your specific plan benefits
Note: Verify your specific plan's formulary and PA requirements at Humana.com/pharmacy/medicare-drug-list or call 1-800-281-6918.

Clinical Criteria for Coverage

Primary Requirements

Humana follows Medicare guidelines for Duopa coverage, requiring documentation of:

Advanced Parkinson's Disease

  • Confirmed diagnosis (ICD-10: G20)
  • Motor fluctuations despite optimized therapy
  • Prescribed by or in consultation with a neurologist/movement disorder specialist

Failed Oral Therapy

  • Optimized carbidopa/levodopa (typically 5+ doses daily)
  • Trial of at least one adjunct medication (MAO-B inhibitor, COMT inhibitor, dopamine agonist, or amantadine) unless contraindicated
  • Documented reasons for failure or intolerance

Significant "OFF" Time

  • At least 3 hours daily of "OFF" time despite optimal oral therapy
  • Objective documentation through patient diaries or clinical assessment
  • Functional impairment during "OFF" periods

Surgical Candidacy

  • Appropriate candidate for PEG-J tube placement
  • Pre-surgical clearance completed
  • No contraindications to enteral infusion

Coding & Billing Requirements

Code Description Unit Notes
J7340 Carbidopa/levodopa enteral suspension 100 mL (1 cassette) Standard daily dose = 1 unit
ICD-10: G20 Parkinson's disease N/A Primary diagnosis
JW modifier Drug discarded/not administered N/A Use for wastage if applicable
Billing tip: Each cassette contains ~100 mL for 16-hour infusion. Bill 1 unit per day for typical use. Document exact dosing and administration instructions in claim narrative.

Documentation Packet

Provider Letter of Medical Necessity Must Include:

  1. Patient demographics and Humana member ID
  2. Diagnosis confirmation with ICD-10 code G20
  3. Detailed medication history:
    • Current and previous carbidopa/levodopa regimens
    • Adjunct medications tried (doses, duration, outcomes)
    • Specific reasons for failure or intolerance
  4. "OFF" time documentation:
    • Duration and frequency of "OFF" episodes
    • Impact on activities of daily living
    • Patient diary data (preferred)
  5. Clinical rationale for Duopa therapy
  6. PEG-J candidacy assessment
  7. Specialist consultation notes

Required Attachments:

  • Movement disorder specialist evaluation
  • Patient "OFF" time diary (1-2 weeks minimum)
  • Medication trial documentation
  • Surgical clearance (if available)
  • Previous therapy failure records

Submission Process

Step-by-Step Submission:

  1. Gather documentation (allow 2-3 weeks)
  2. Complete PA request through Humana provider portal or via fax
  3. Submit required attachments with clear labeling
  4. Follow up within 5-7 business days for confirmation
  5. Track status through portal or member services

Timeline: Standard PA decisions within 30 days; expedited requests within 72 hours for urgent cases.

Portal access: Submit through Availity portal or call 1-866-488-5995 for assistance.

Specialty Pharmacy Routing

Humana uses CenterWell Specialty Pharmacy as their preferred specialty medication vendor. Once approved:

  1. Prescription routing: Your doctor sends the prescription to CenterWell
  2. Coordination services: CenterWell handles PEG-J pump setup and supplies
  3. Direct delivery: Medications shipped to your home
  4. Clinical support: Ongoing therapy management and monitoring

Contact: Verify current specialty pharmacy network at Humana.com/finder/pharmacy.

After Submission

What to Track:

  • Confirmation number from submission
  • Review timeline (standard 30 days)
  • Additional information requests from Humana
  • Decision notification method (mail, portal, phone)

Status Check Schedule:

  • Week 1: Confirm receipt of PA request
  • Week 2-3: Check for additional information requests
  • Week 4: Follow up if no decision received
  • After denial: Begin appeal process immediately

Appeals Playbook for New York

Humana Internal Appeal Process:

Timeline: 65 days from denial notice to file appeal How to file:

  • Online through Humana member portal
  • Mail to address on denial letter
  • Fax: (verify current number with member services)

Required documents:

  • Copy of denial letter
  • Updated physician letter addressing denial reasons
  • Additional clinical evidence
  • Patient impact statement

New York External Review:

If Humana upholds the denial, New York residents can request external review through the Department of Financial Services (DFS).

Timeline: 4 months from final internal denial How to file: DFS External Appeal Portal or mail forms Cost: $25 maximum (waived for financial hardship/Medicaid) Decision timeline:

  • Standard: 30 days
  • Expedited: 72 hours (24 hours for urgent drug denials)
New York advantage: DFS external reviewers overturn many specialty drug denials when proper medical evidence is provided. Their decisions are binding on insurers.

Common Denial Reasons & Solutions

Denial Reason Solution
Insufficient "OFF" time documentation Submit detailed patient diary showing 3+ hours daily "OFF" time
Missing specialist consultation Obtain movement disorder specialist evaluation and letter
Inadequate oral therapy trials Document specific medications, doses, duration, and failure reasons
Surgical candidacy unclear Provide pre-surgical evaluation and PEG-J placement clearance
Coding/billing errors Verify J7340 units calculation and required modifiers

Cost-Saving Options

  • AbbVie Patient Assistance: Income-based support program for eligible patients
  • Medicare Extra Help: Low-income subsidy for Part D costs
  • New York State programs: EPIC (Elderly Pharmaceutical Insurance Coverage) for additional assistance
  • Copay cards: May be available for non-Medicare patients

Cost context: Duopa wholesale cost ~$7,000/month plus pump and supply expenses.

Quick Reference Checklist

Before You Start:

  • Active Humana coverage verified
  • Advanced Parkinson's diagnosis confirmed
  • Movement disorder specialist involved
  • "OFF" time diary completed (1-2 weeks)
  • Oral medication trial documentation gathered
  • Surgical clearance obtained or scheduled

PA Submission:

  • Provider letter of medical necessity complete
  • All required attachments included
  • Submission via correct portal/fax
  • Confirmation number recorded
  • Follow-up scheduled

If Denied:

  • Internal appeal filed within 65 days
  • Additional evidence gathered
  • External review option researched
  • New York DFS contact information saved

From our advocates: We've seen many Duopa appeals succeed when families take time to document "OFF" episodes thoroughly. One patient's detailed diary showing specific times when medication wore off—and how it affected daily activities like eating and dressing—helped overturn an initial denial. The key is painting a clear picture of how motor fluctuations impact quality of life despite optimal oral therapy.

Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals for patients seeking coverage of specialty medications like Duopa. Our platform helps identify denial reasons and drafts point-by-point rebuttals aligned with each payer's specific requirements, saving time for patients, clinicians, and specialty pharmacies while improving approval rates.

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 over time. Always verify current requirements with your insurer and consult your healthcare provider for medical decisions. For personalized assistance with New York insurance appeals, contact Community Health Advocates at 888-614-5400.

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