By Counterforce Health Team in Idelvion (albutrepenonacog alfa; rFIX-FP) —

How to Get Idelvion (Albutrepenonacog Alfa) Covered by UnitedHealthcare in New York: Prior Authorization, Appeals, and Coding Guide

Answer Box: Getting Idelvion Covered by UnitedHealthcare in New York

Yes, UnitedHealthcare covers Idelvion (albutrepenonacog alfa) in New York, but requires prior authorization and often step therapy. The fastest path: Have your hematologist submit a PA request through the UnitedHealthcare Provider Portal using ICD-10 code D67 and HCPCS code J7202, documenting failed standard factor IX therapy. If denied, you can appeal internally (180 days) then request external review through New York's DFS portal (4 months). Start today: Call UnitedHealthcare member services at the number on your card to confirm your plan's specific requirements.

Table of Contents

  1. Coverage Requirements at a Glance
  2. Essential Coding for Clean Claims
  3. Step-by-Step: Fastest Path to Approval
  4. Common Denial Reasons & How to Fix Them
  5. Appeals Process in New York
  6. Cost Assistance Options
  7. When to Contact State Regulators
  8. Frequently Asked Questions

Coverage Requirements at a Glance

Requirement Details Where to Find It Source
Prior Authorization Required for all strengths UnitedHealthcare Provider Portal UHC Provider Portal
Step Therapy Must try standard half-life factor IX first Plan formulary documents OptumRx Coverage Policies
ICD-10 Code D67 (Hereditary Factor IX deficiency) Claims submission guidelines AAPC ICD-10 Reference
HCPCS Code J7202 (1 IU billing unit) Medicare fee schedules AAPC HCPCS Reference
Prescriber Requirement Hematologist preferred PA submission forms Plan-specific requirements
Appeal Deadline 180 days internal, 4 months external Member handbook NY DFS External Appeals

Essential Coding for Clean Claims

Medical vs. Pharmacy Benefit Pathways

Idelvion typically falls under the medical benefit when administered in clinical settings or the pharmacy benefit for home infusion. UnitedHealthcare requires prior authorization regardless of pathway.

ICD-10 Coding Requirements

Primary Code: D67 - Hereditary factor IX deficiency (Hemophilia B)

Your documentation should include:

  • Confirmed diagnosis with factor IX activity levels
  • Bleeding episode history and severity
  • Previous treatment responses
  • Inhibitor testing results

HCPCS and NDC Coding

HCPCS Code: J7202 - Injection, factor IX, albumin fusion protein (recombinant), Idelvion, 1 IU per billing unit

NDC Codes by Strength:

  • 250 IU: 69911-0864-02
  • 500 IU: 69911-0865-02
  • 1000 IU: 69911-0866-02
  • 2000 IU: 69911-0867-02
  • 3500 IU: 69911-0869-02

Dosing Calculations

Formula: Weight (kg) × Desired Factor IX Rise (%) × 1.3 = IU required (for patients ≥12 years)

For patients under 12: Use 1.0 instead of 1.3 as the recovery factor.

Billing Modifiers:

  • JW: Drug amount discarded
  • JZ: Zero drug amount discarded

Step-by-Step: Fastest Path to Approval

1. Verify Coverage and Requirements

Who: Patient or clinic staff
Action: Log into UnitedHealthcare member portal or call member services
Timeline: Same day
Document: Screenshot of formulary status and PA requirements

2. Gather Clinical Documentation

Who: Hematologist and clinic staff
Required documents:

  • Complete hemophilia B diagnosis with lab values
  • Bleeding diary or episode history
  • Documentation of failed standard factor IX therapy (≥50 exposure days preferred)
  • Current factor IX inhibitor status Timeline: 1-2 business days

3. Submit Prior Authorization Request

Who: Prescribing physician
Method: UnitedHealthcare Provider Portal (electronic submission required since June 2025)
Include: All clinical documentation, dosing calculations, and treatment plan
Timeline: Submit within 24-48 hours of gathering documents

4. Track PA Status

Who: Clinic staff or patient
Method: Provider portal or member services phone line
Timeline: Check every 3-5 business days
Expected decision: 15 business days for standard review, 72 hours for urgent

5. If Denied: Request Peer-to-Peer Review

Who: Prescribing physician
Action: Contact UnitedHealthcare medical director for clinical discussion
Timeline: Within 5 business days of denial
Outcome: Often resolves denials when clinical rationale is strong

6. File Internal Appeal if Necessary

Who: Patient or authorized representative
Deadline: 180 days from denial date
Method: UnitedHealthcare appeals portal or written submission
Include: New clinical evidence, physician letter, bleeding diary updates

7. Request External Review (New York)

Who: Patient
Deadline: 4 months after final internal denial
Method: New York DFS portal online submission
Timeline: 30 days for standard, 72 hours for expedited

Tip: Keep detailed records of all communications, including reference numbers and representative names. This documentation becomes crucial if you need to escalate to appeals.

Common Denial Reasons & How to Fix Them

Denial Reason How to Overturn Required Documentation
"Step therapy not completed" Document failed standard factor IX therapy Treatment records showing ≥50 exposure days, breakthrough bleeding episodes, or intolerance
"Not medically necessary" Provide clinical justification from hematologist Detailed physician letter citing bleeding frequency, severity, and impact on quality of life
"Experimental/investigational" Reference FDA approval and guidelines FDA prescribing information, WFH treatment guidelines, peer-reviewed studies
"Quantity limits exceeded" Justify dosing based on patient weight and severity Pharmacokinetic studies, individualized dosing calculations, bleeding diary
"Site of care restriction" Document medical necessity for home infusion Patient age, caregiver capability, travel distance to infusion center

Appeals Process in New York

New York offers robust patient protections for insurance denials, including binding external review through the Department of Financial Services.

Internal Appeals with UnitedHealthcare

Level 1 Internal Appeal

  • Deadline: 180 days from denial
  • Method: Electronic submission through provider/member portal (required since June 2025)
  • Timeline: 30 days for standard, 72 hours for expedited
  • Required: New clinical evidence, physician support letter

Level 2 Internal Appeal (if applicable)

  • Deadline: 60 days from Level 1 denial
  • Method: Same as Level 1
  • Timeline: 30 days for decision

External Review Through New York DFS

After exhausting internal appeals, New York residents can request binding external review.

Eligibility Requirements:

  • Final adverse determination from UnitedHealthcare
  • Denial based on medical necessity, experimental status, or coverage exclusion
  • Treatment would be covered benefit if not for the denial reason

How to File:

  1. Submit request through DFS External Appeal Portal (verify current link)
  2. Include all denial letters, clinical records, and physician statements
  3. Pay $25 filing fee (waived for financial hardship or Medicaid)

Timeline: 30 days for standard review, 72 hours for expedited (24 hours for urgent drug requests)

Success Rate: New York's external review program has historically overturned 30-40% of denials, particularly for rare disease treatments with strong clinical evidence.

Getting Help with Appeals

Community Health Advocates (CHA)

  • Phone: 888-614-5400
  • Email: [email protected]
  • Services: Free assistance with appeals, form completion, and advocacy
  • Website: communityhealthadvocates.org

New York DFS Consumer Hotline

  • Phone: 800-342-3736
  • Services: General insurance complaints and appeal guidance
Note: Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals. Their platform analyzes denial letters and plan policies to draft point-by-point rebuttals aligned with payer-specific requirements, potentially saving weeks of back-and-forth with insurers.

Cost Assistance Options

Manufacturer Support Programs

CSL Behring Patient Support

  • Copay assistance for eligible commercially insured patients
  • Free drug programs for uninsured patients meeting income criteria
  • Contact: 1-844-727-2752

Foundation Grants

National Hemophilia Foundation

  • Emergency financial assistance
  • Insurance premium support
  • Website: hemophilia.org

Patient Access Network Foundation

  • Copay assistance for bleeding disorders
  • Website: panfoundation.org

State Programs

New York State of Health

  • Medicaid expansion covers adults up to 138% of federal poverty level
  • Child Health Plus for children in families up to 400% FPL
  • Essential Plan for adults 138-200% FPL

When to Contact State Regulators

Contact New York regulators if:

  • UnitedHealthcare fails to meet appeal deadlines
  • You experience repeated inappropriate denials
  • The insurer doesn't follow New York insurance laws

New York Department of Financial Services

  • Consumer Complaints: File online at dfs.ny.gov
  • Phone: 800-342-3736
  • Include: Policy number, denial letters, timeline of events, financial impact

Frequently Asked Questions

How long does UnitedHealthcare prior authorization take in New York? Standard PA decisions are made within 15 business days. Urgent requests (when delay could seriously jeopardize health) must be decided within 72 hours.

What if Idelvion is not on my plan's formulary? Non-formulary drugs can still be covered through the exceptions process. Your doctor must document medical necessity and why formulary alternatives are inappropriate.

Can I request an expedited appeal? Yes, if waiting for the standard timeline could seriously jeopardize your health or ability to regain maximum function. Include a physician statement supporting urgency.

Does step therapy apply if I tried standard factor IX outside New York? Yes, treatment history from other states counts toward step therapy requirements. Ensure your new provider obtains complete medical records.

What happens if I lose my appeal? After exhausting internal appeals, you can request external review through New York DFS. Their decision is binding on UnitedHealthcare and has a filing fee of only $25.

How much does Idelvion cost without insurance? Retail prices vary significantly by strength and pharmacy. The manufacturer offers patient assistance programs that can reduce out-of-pocket costs to as low as $10 per prescription for eligible patients.

Can I switch to a different UnitedHealthcare plan during open enrollment? Yes, but check if Idelvion coverage differs between plan types. Some plans may have more restrictive formularies or higher cost-sharing.

What if my doctor isn't a hematologist? While UnitedHealthcare may prefer hematologist prescribing, other specialists familiar with bleeding disorders can often obtain approval with strong clinical documentation. Consider getting a hematology consultation to strengthen your case.

From our advocates: "We've seen patients succeed by keeping detailed bleeding diaries that document every episode, including date, severity, treatment required, and impact on daily activities. This concrete evidence often makes the difference in overturning 'not medically necessary' denials, especially when combined with pharmacokinetic data showing why extended half-life products are clinically superior for that individual patient."

For complex cases requiring detailed appeal strategy, Counterforce Health's platform can analyze your specific denial and create targeted rebuttals that address UnitedHealthcare's exact coverage criteria, potentially improving your chances of approval.

Sources & Further Reading

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 personalized guidance. Coverage policies and requirements may change; verify current information with official sources.

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