By Counterforce Health Team in Gattex (teduglutide) —

How to Get Gattex (Teduglutide) Covered by Blue Cross Blue Shield in New York: Complete Appeals Guide with Forms and Timelines

Blue Cross Blue Shield in New York requires prior authorization for Gattex (teduglutide) with specific criteria: confirmed short bowel syndrome with parenteral nutrition dependence (≥3 days/week), documented enteral nutrition optimization failure, baseline colonoscopy within 6 months, and GI specialist involvement. If denied, file an internal appeal within 30 days, then escalate to New York State Department of Financial Services external review within 4 months. Start by calling the member services number on your insurance card to verify your plan's formulary status and submit a complete prior authorization packet through your provider's Blue Cross Blue Shield portal.

Table of Contents

Coverage Requirements at a Glance

Requirement What It Means Where to Find It
Prior Authorization Required for all Blue Cross Blue Shield plans Blue Cross Blue Shield provider portal
Age Eligibility ≥1 year old FDA label
Diagnosis Short bowel syndrome with parenteral nutrition dependence ICD-10: K91.2 (postsurgical malabsorption)
PN Requirements ≥3 days/week for ≥12 months Blue Cross Blue Shield policy
Monitoring Colonoscopy within 6 months; labs every 6 months Anthem BCBS criteria
Appeal Deadline 30 days internal; 4 months external NY DFS external appeals

Step-by-Step: Fastest Path to Approval

1. Verify Coverage and Formulary Status

Who does it: Patient or clinic staff
Action: Call the member services number on your Blue Cross Blue Shield card
What to ask: "Is Gattex (teduglutide) on our formulary? What tier? Does it require prior authorization?"
Timeline: 5-10 minutes

2. Gather Required Documentation

Who does it: GI specialist and care team
Documents needed:

  • Parenteral nutrition logs (30-90 days showing volume, frequency)
  • Surgical reports confirming short bowel anatomy
  • Records of failed enteral nutrition trials
  • Recent colonoscopy report (within 6 months)
  • Baseline labs: bilirubin, alkaline phosphatase, lipase, amylase
  • Weight trends and nutritional assessments

Timeline: 1-2 weeks to compile

3. Submit Prior Authorization Request

Who does it: Prescribing physician
How: Through Blue Cross Blue Shield provider portal or fax
Include: Completed PA form, medical necessity letter, all supporting documentation
Timeline: Decision within 15 business days (72 hours if expedited)

4. Monitor Decision and Prepare for Possible Denial

Action: Track status through provider portal
If approved: Coordinate with specialty pharmacy for delivery
If denied: Immediately request detailed denial letter with specific reason codes

5. File Internal Appeal if Denied

Timeline: Within 30 days of denial
Submit to: Blue Cross Blue Shield appeals department via portal or mail
Include: Appeal letter addressing specific denial reasons, additional clinical evidence, peer-reviewed literature

6. Request Peer-to-Peer Review

When: After initial denial, before or during internal appeal
Who: GI specialist calls Blue Cross Blue Shield medical director
Prep: 2-3 minute script covering diagnosis, failed alternatives, clinical necessity

7. Escalate to External Review if Needed

When: After final internal denial
Timeline: Within 4 months
Submit to: New York State Department of Financial Services
Cost: Up to $25 (refunded if you win)

Common Denial Reasons & How to Fix Them

Denial Reason How to Overturn
"No documented SBS with PN dependence" Submit surgical records, imaging showing bowel length, detailed PN logs with dates/volumes
"Inadequate enteral nutrition trial" Document specific formulas tried, durations, tolerance issues, nutritionist consultation notes
"Missing baseline monitoring" Schedule and submit colonoscopy within 6 months, complete lab panel
"Quantity over limits" Provide weight-based dosing calculation (0.05 mg/kg/day), physician attestation for dose
"Not medically necessary" Include peer-reviewed studies, FDA labeling, GI society guidelines supporting use

Appeals Playbook for Blue Cross Blue Shield in New York

Internal Appeals (First Level)

Timeline: 30 days to file, 15 business days for decision
How to file: Blue Cross Blue Shield member portal or mail to address on denial letter
Required: Completed appeal form, medical records, physician letter
Expedited option: 72 hours if delay could seriously jeopardize health

Peer-to-Peer Review

When to request: Immediately after denial
Who participates: Prescribing GI specialist and Blue Cross Blue Shield medical director
Scheduling: Call member services number to request
Preparation time: 2-3 minutes for clinical discussion

External Review (New York State)

Eligibility: After exhausting internal appeals
Timeline: 4 months to file, 30 days for decision (72 hours expedited)
Cost: $25 maximum (waived for financial hardship)
Forms: NY External Appeal Application
Decision: Binding on Blue Cross Blue Shield

From our advocates: We've seen cases where patients initially denied for "insufficient PN documentation" won on appeal by submitting home health nursing logs that clearly showed daily PN volumes and infusion schedules over 12+ months. The key was organizing the data into a clear timeline that demonstrated both medical necessity and compliance with Blue Cross Blue Shield criteria.

Medical Necessity Letter Requirements

Your GI specialist's letter should address these key points:

Clinical Necessity Checklist:

  • ✓ Confirmed SBS diagnosis with surgical history/imaging
  • ✓ Parenteral nutrition dependence (volume, frequency, duration)
  • ✓ Failed enteral nutrition optimization (specific formulas, outcomes)
  • ✓ Absence of contraindications (active malignancy, obstruction)
  • ✓ Appropriate dosing (0.05 mg/kg/day subcutaneously)
  • ✓ Treatment goals (PN reduction, improved absorption)
  • ✓ Monitoring plan (labs every 6 months, colonoscopy)

Supporting Evidence to Include:

  • FDA prescribing information
  • Clinical trial data showing PN reduction in 63-69% of patients
  • AGA guidelines endorsing teduglutide for SBS management
  • Peer-reviewed studies on intestinal adaptation

Scripts & Templates

Patient Phone Script for Blue Cross Blue Shield

"Hi, I'm calling about prior authorization for Gattex, generic name teduglutide, for short bowel syndrome. My member ID is [ID]. Can you tell me if this medication is covered on my plan and what the prior authorization requirements are? I also need to know the specific forms my doctor needs to complete and where to submit them."

Peer-to-Peer Request Script for Clinic Staff

"I'm calling to request a peer-to-peer review for [patient name], member ID [ID], regarding the denial of Gattex for short bowel syndrome. Dr. [Name], the patient's gastroenterologist, would like to speak directly with your medical director about the clinical necessity. When is the earliest available time slot?"

Appeal Letter Template

Re: Appeal for Gattex (teduglutide) Coverage
Patient: [Name, DOB]
Member ID: [ID]
Denial Date: [Date]

Dear Blue Cross Blue Shield Appeals Team,

I am appealing your denial of Gattex (teduglutide) for [patient name], which was denied on [date] for [specific reason from denial letter].

MEDICAL NECESSITY:
[Patient] has confirmed short bowel syndrome following [surgical procedure/condition] with documented parenteral nutrition dependence of [X] liters per week over [X] days for [duration]. Despite optimization of enteral feeding including [specific formulas and interventions], the patient continues to require substantial parenteral support.

CLINICAL EVIDENCE:
Gattex is FDA-approved for this exact indication and has demonstrated significant reduction in parenteral nutrition requirements in clinical trials. Continued parenteral nutrition dependence places [patient] at risk for [specific complications].

SUPPORTING DOCUMENTATION:
- Surgical records confirming bowel anatomy
- Parenteral nutrition logs (attached)
- Failed enteral trial documentation
- Recent colonoscopy results
- Laboratory monitoring

I request immediate approval of Gattex at the FDA-approved dose of 0.05 mg/kg/day.

Sincerely,
[Physician name, credentials]

When Appeals Fail: Alternative Options

If your Blue Cross Blue Shield appeals are unsuccessful, consider these options:

Manufacturer Support:

State Resources:

Alternative Approaches:

  • Formulary exception request for non-formulary status
  • Step therapy override documentation
  • Site-of-care exception if restricted to certain facilities

Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into targeted, evidence-backed appeals. The platform analyzes denial letters and plan policies to draft point-by-point rebuttals aligned with each payer's specific requirements, incorporating the right clinical evidence and procedural details that insurers expect.

FAQ

How long does Blue Cross Blue Shield prior authorization take in New York? Standard prior authorization decisions are made within 15 business days. Expedited reviews for urgent medical needs must be completed within 72 hours.

What if Gattex is non-formulary on my Blue Cross Blue Shield plan? You can request a formulary exception by demonstrating medical necessity and that formulary alternatives are inappropriate or have failed. This requires additional documentation of contraindications or treatment failures.

Can I request an expedited appeal if I'm hospitalized? Yes, if delay in treatment could seriously jeopardize your health or ability to regain maximum function, you can request expedited review with decisions in 72 hours for internal appeals and 24-72 hours for external review.

Does step therapy apply if I've tried treatments outside New York? Medical records from any state are acceptable to document prior treatment failures, as long as they're complete and clearly show inadequate response or intolerance to required step therapy medications.

What happens if I win an external appeal in New York? The decision is binding on Blue Cross Blue Shield, and they must cover the treatment. You'll also receive a refund of the $25 appeal fee if you paid one.

How much does Gattex cost without insurance? The wholesale acquisition cost is approximately $46,893 per 30-vial kit or $1,798 per single vial. Manufacturer assistance programs may help reduce out-of-pocket costs.

Can my doctor prescribe Gattex off-label for other conditions? Gattex is FDA-approved specifically for short bowel syndrome in patients requiring parenteral support. Off-label use would require additional justification and is less likely to be covered by insurance.

What if my Blue Cross Blue Shield plan changes its formulary mid-year? Plans can make mid-year formulary changes but must provide 60 days notice and continue coverage during appeals processes. You have the right to request exceptions based on medical necessity.

Sources & Further Reading:

For additional support with complex insurance appeals, Counterforce Health provides specialized assistance in developing evidence-based appeals that address specific payer requirements and improve approval rates for specialty medications.

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage varies by plan and individual circumstances. Always consult with your healthcare provider and insurance company for guidance specific to your situation. Coverage criteria and appeal processes may change; verify current requirements with your Blue Cross Blue Shield plan and New York State Department of Financial Services.

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