By Counterforce Health Team in Humate-P (antihemophilic factor/vWF complex) —

How to Get Humate-P Covered by Humana in Ohio: Coding, Appeals, and Prior Authorization Guide

Answer Box: Getting Humate-P Covered by Humana in Ohio

Humate-P requires prior authorization from Humana Medicare Advantage plans in Ohio as of 2025. The fastest path to approval: (1) Submit a complete PA request with specific VWD subtype documentation and ICD-10 codes (D68.01 for Type 1, D68.02A for Type 2A), (2) Include lab results showing VWF:RCo levels and failed alternatives like desmopressin when appropriate, and (3) Use correct HCPCS code J7187 with NDC-specific unit billing. If denied, you have 65 days to appeal internally, then can request external review through Ohio's Department of Insurance within 180 days.

Table of Contents

  1. Coding Basics: Medical vs. Pharmacy Benefit
  2. ICD-10 Mapping and Documentation
  3. Product Coding: HCPCS, J-Codes, and NDC
  4. Clean Request Anatomy
  5. Frequent Pitfalls
  6. Verification with Humana
  7. Appeals Process in Ohio
  8. Quick Audit Checklist

Coding Basics: Medical vs. Pharmacy Benefit

Humate-P (antihemophilic factor/von Willebrand factor complex) typically falls under the medical benefit rather than pharmacy for most Humana plans. This plasma-derived concentrate is administered in clinical settings for acute bleeding episodes, surgical prophylaxis, or ongoing treatment of von Willebrand disease and Hemophilia A.

Key Coverage Points:

  • Prior authorization required for Humana Medicare Advantage plans
  • Buy-and-bill model through medical benefit
  • Reimbursed via HCPCS J-codes with ASP pricing updates
  • Site-of-care restrictions may apply (infusion centers vs. home administration)
Note: While Humana plans to reduce prior authorizations by one-third starting January 2026, Humate-P remains on the PA list as of October 2025.

ICD-10 Mapping and Documentation

Proper diagnosis coding is critical for Humate-P approval. Vague or unspecified codes increase denial risk and audit exposure.

Primary ICD-10 Codes

ICD-10 Code Description Documentation Required
D68.01 Von Willebrand disease, type 1 VWF:Ag 30-50 IU/dL, bleeding history
D68.02A Von Willebrand disease, type 2A Multimer analysis, specific subtype confirmation
D68.0 Von Willebrand disease (unspecified) Basic lab evidence (use only if subtype unknown)
D66 Hemophilia A Factor VIII deficiency documentation

Supporting Documentation Language

Your medical records should include:

  • Specific subtype identification: "Patient diagnosed with von Willebrand disease Type 1 based on..."
  • Laboratory evidence: Include actual VWF antigen, cofactor activity levels, and dates
  • Bleeding history: Document spontaneous bleeding episodes, surgical complications, or family history
  • Treatment rationale: Why Humate-P is medically necessary over alternatives
Tip: The American Society of Hematology recommends using the most specific ICD-10 code available to support reimbursement.

Product Coding: HCPCS, J-Codes, and NDC

HCPCS J-Code and Units

Primary Code: J7187 (von Willebrand factor, human, per IU VWF:RCo)

Critical Billing Rule: Bill Humate-P by ristocetin cofactor activity units (VWF:RCo) printed on each vial—not Factor VIII units.

NDC Codes by Strength

Strength NDC Code Units per Vial
600 VWF:RCo units 63833-615-02 600
1200 VWF:RCo units 63833-616-02 1200
2400 VWF:RCo units 63833-617-02 2400

Dosing Calculation

Use this formula for unit requirements:

Units required = [(Target Level - Baseline Level) × Body Weight (kg)] / IVR (IU/dL per IU/kg)

Always bill the full VWF:RCo unit count per vial used—partial units are not typically reimbursed.

Important: CSL Behring provides reimbursement support and coding guidance for healthcare providers.

Clean Request Anatomy

Essential Components for PA Approval

Patient Information:

  • Full name, DOB, Humana member ID
  • Prescribing physician NPI and contact information
  • Diagnosis with specific ICD-10 code

Clinical Justification:

  • Documented bleeding episodes or surgical need
  • Laboratory results (VWF studies, factor levels)
  • Previous treatment attempts and outcomes
  • Contraindications to alternatives (e.g., desmopressin)

Product Details:

  • Exact NDC code for strength prescribed
  • Units required per dose and frequency
  • Duration of treatment
  • Site of administration

Sample Documentation Framework

"Patient is a [age]-year-old with confirmed von Willebrand disease Type 1 (ICD-10: D68.01) based on VWF:Ag level of [X] IU/dL and VWF:RCo of [Y] IU/dL obtained on [date]. Previous trial of desmopressin resulted in [inadequate response/contraindication]. Humate-P is medically necessary for [bleeding control/surgical prophylaxis] at [X] units per dose."

Frequent Pitfalls

Common Coding Errors

  1. Wrong unit billing: Using Factor VIII units instead of VWF:RCo units
  2. NDC mismatch: Billing NDC doesn't match actual vial strength used
  3. Incomplete diagnosis: Using D68.0 when specific subtype is known
  4. Missing step therapy: No documentation of desmopressin trial when clinically appropriate

Documentation Gaps

  • Vague bleeding history without specific episodes
  • Missing laboratory dates or reference ranges
  • Inadequate rationale for dose/frequency
  • No mention of alternative treatments considered
From our advocates: We've seen cases where providers documented "bleeding disorder" instead of the specific VWD subtype, leading to automatic denials. Taking time to use precise diagnostic language and include actual lab values significantly improves approval rates.

Verification with Humana

Pre-Submission Checklist

Before submitting your PA request:

  1. Confirm current PA requirements using Humana's prior authorization search tool
  2. Check formulary status on the member's specific plan
  3. Verify correct forms through the Humana provider portal
  4. Confirm submission method (electronic portal vs. fax)

Expected Timeline

  • Complete electronic requests: Most decisions within 1 business day
  • Standard reviews: Up to 30 days for Part C determinations
  • Expedited reviews: 72 hours when urgency is documented

Counterforce Health helps streamline this process by automatically identifying denial reasons and drafting evidence-backed appeals that align with each payer's specific requirements, saving valuable time for both patients and providers.

Appeals Process in Ohio

Internal Appeal (First Level)

If your initial PA is denied:

  1. File within 65 days of denial notice
  2. Submit through Humana member portal or provider portal
  3. Include new evidence: Additional lab results, peer-reviewed studies, specialist letters
  4. Timeline: 7 calendar days for standard appeals

External Review (Ohio Department of Insurance)

After exhausting Humana's internal appeals:

  1. Eligibility: Medical necessity denials qualify for external review
  2. Timeline: Request within 180 days of final internal denial
  3. Process: Independent Review Organization (IRO) conducts medical review
  4. Decision timeframe: 45 days standard, 72 hours expedited
  5. Cost: No charge to the member

Contact for assistance: Ohio Department of Insurance Consumer Hotline: 800-686-1526

Expedited Appeals

Available when delays could jeopardize health:

  • Physician must certify medical urgency
  • Can be submitted by phone initially
  • 24-hour decision timeline for internal appeals
  • 72-hour decision for external reviews

Quick Audit Checklist

Before submitting any Humate-P request or claim:

✓ Diagnosis Coding

  • Most specific ICD-10 code used (D68.01, D68.02A vs. D68.0)
  • Supporting lab values documented with dates
  • Bleeding history or surgical indication clear

✓ Product Coding

  • J7187 HCPCS code confirmed
  • Correct NDC for actual vial strength
  • Units billed match VWF:RCo units (not Factor VIII)
  • Dosing calculation documented

✓ Medical Necessity

  • Alternative treatments addressed (desmopressin, other factors)
  • Clinical rationale for Humate-P specifically
  • Treatment goals and monitoring plan included
  • Provider specialty and experience noted

✓ Administrative

  • Current PA requirements verified
  • Complete prescriber information (NPI, contact)
  • Member ID and demographics accurate
  • Submission deadline met

Frequently Asked Questions

How long does Humana prior authorization take for Humate-P in Ohio? Most complete electronic submissions receive decisions within 1 business day. Standard reviews can take up to 30 days for Medicare Advantage plans.

What if Humate-P is non-formulary on my plan? You can request a formulary exception with medical necessity documentation. The process is similar to PA but requires demonstrating that preferred alternatives are inappropriate.

Can I get an expedited appeal if denied? Yes, if your physician certifies that delays could jeopardize your health. Expedited internal appeals are decided within 24 hours.

Does step therapy apply to Humate-P? It may, particularly requiring trial of desmopressin for appropriate VWD types. Document medical reasons if step therapy isn't clinically appropriate.

What happens if my external review is denied? The IRO decision is binding on Humana. If overturned in your favor, coverage must be provided. If upheld, you retain rights to legal remedies or regulatory complaints.

Medical Disclaimer: This information is for educational purposes and does not constitute medical advice. Coverage decisions depend on individual medical circumstances and specific plan benefits. Always consult with your healthcare provider and insurance plan for personalized guidance.

For complex cases requiring detailed appeal strategies, Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals by identifying specific denial reasons and crafting responses aligned to each payer's requirements.

Sources & Further Reading

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