By Counterforce Health Team in Increlex (mecasermin) —

How to Get Increlex (Mecasermin) Covered by Humana in Illinois: Decision Tree & Appeal Guide

Quick Answer: Increlex (mecasermin) coverage by Humana requires severe primary IGF-1 deficiency diagnosis with height SDS ≤ -3.0, IGF-1 SDS ≤ -3.0, and normal/elevated growth hormone levels. Contact Humana Clinical Pharmacy Review at 800-555-2546 for prior authorization. If denied, Illinois residents have strong appeal rights including automatic external review. First step today: Gather diagnostic labs (IGF-1, GH stimulation test) and contact your pediatric endocrinologist to initiate the prior authorization process.

Table of Contents

How to Use This Guide

This guide helps you navigate Humana's prior authorization process for Increlex (mecasermin) in Illinois. Start with the eligibility decision tree below to determine your pathway. Each section provides specific documents, timelines, and contact information you'll need.

Note: Increlex is the only FDA-approved treatment for severe primary IGF-1 deficiency. It's not indicated for growth hormone deficiency or secondary causes of short stature.

Eligibility Decision Tree

Step 1: Confirm Your Diagnosis

Do you have severe primary IGF-1 deficiency? This requires:

  • Height standard deviation score (SDS) ≤ -3.0
  • IGF-1 SDS ≤ -3.0
  • Normal or elevated growth hormone levels
  • Age 2-18 years
  • No underlying conditions causing secondary IGF-1 deficiency

Sources: FDA Increlex labeling, Humana coverage policy

Step 2: Check Required Laboratory Tests

Have you completed these tests?

  • Serum IGF-1 assay with age-adjusted reference ranges
  • Growth hormone stimulation test (arginine, insulin, or clonidine)
  • Thyroid function panel
  • Complete metabolic panel
  • Nutritional assessment
  • Bone age X-ray

Step 3: Verify Specialist Involvement

Is a pediatric endocrinologist involved in your care? Humana typically requires specialist consultation or direct prescribing for Increlex approval.

If You're Likely Eligible: Document Checklist

✅ Clinical Documentation Required:

  • Growth charts showing height SDS ≤ -3.0
  • Laboratory reports with IGF-1 SDS ≤ -3.0
  • GH stimulation test results (normal/elevated)
  • Pediatric endocrinologist consultation notes
  • Bone age assessment
  • Documentation excluding secondary causes

✅ Submission Process:

  1. Contact Humana Clinical Pharmacy Review: 800-555-2546 (Monday-Friday, 8 AM-6 PM ET)
  2. Submit prior authorization request with complete documentation
  3. Expected timeline: 30 days for standard review, 72 hours for expedited
  4. Follow up if no response within expected timeframe
Clinician Corner: Medical necessity letters should explicitly state height and IGF-1 z-scores, document normal GH secretion, and exclude malnutrition, hypothyroidism, and chronic disease. Include references to FDA labeling criteria.

If You're Possibly Eligible: Tests to Request

Missing diagnostic criteria? Request these from your healthcare provider:

Laboratory Tests Needed

  • IGF-1 measurement: Must be performed with age-adjusted reference ranges
  • GH stimulation testing: Required to rule out GH deficiency
  • Comprehensive metabolic panel: To exclude secondary causes
  • Thyroid function tests: TSH, free T4 to rule out hypothyroidism

Timeline for Re-application

  • Allow 2-4 weeks for test completion
  • Schedule follow-up with pediatric endocrinologist
  • Resubmit prior authorization with complete documentation

If You're Not Yet Eligible: Alternative Options

When Increlex May Not Be Covered

  • Growth hormone deficiency: Standard GH therapy is first-line treatment
  • Secondary IGF-1 deficiency: Treat underlying condition (malnutrition, hypothyroidism)
  • Insufficient documentation: Complete diagnostic workup required

Exception Request Process

If you don't meet standard criteria but have compelling clinical circumstances:

  1. Request formulary exception through Humana
  2. Provide detailed clinical justification
  3. Consider peer-to-peer review with Humana medical director

If Denied: Illinois Appeal Process

Illinois residents have robust appeal rights, including automatic external review for medical necessity denials.

Internal Appeal (First Level)

  • Deadline: 65 days from denial notice
  • How to file: Call Humana member services or submit written appeal
  • Timeline: 15 business days for pre-service decisions
  • Required: Copy of denial letter, supporting clinical documentation

External Review (Automatic in Illinois)

Starting April 2025, medical necessity denials are automatically forwarded for external review unless you opt out.

  • Timeline: 45 days for standard review, 72 hours for expedited
  • Reviewer: Board-certified specialist in pediatric endocrinology
  • Cost: Free to patients
  • Decision: Binding on Humana

Contact for assistance: Illinois Attorney General Health Care Helpline: 1-877-305-5145

Coverage Requirements at a Glance

Requirement Details Documentation Needed Source
Age 2-18 years Medical records FDA Label
Height SDS ≤ -3.0 Growth charts, calculations Humana Policy
IGF-1 SDS ≤ -3.0 Lab results with age-adjusted ranges FDA Label
GH Status Normal or elevated GH stimulation test Clinical Guidelines
Prescriber Pediatric endocrinologist Consultation notes Humana Policy
Prior Authorization Required Complete application Humana HCPR

Common Denial Reasons & How to Fix Them

Denial Reason How to Overturn Required Documentation
"Not primary IGF-1 deficiency" Submit GH stimulation test showing normal/elevated levels Lab reports, endocrinologist letter
"Insufficient laboratory evidence" Provide age-adjusted IGF-1 results with clear SDS calculations Certified lab results with reference ranges
"Missing specialist consultation" Obtain pediatric endocrinology evaluation Consultation notes, treatment plan
"Safety concerns not addressed" Submit hypoglycemia monitoring plan Glucose monitoring protocol, family education

From our advocates: We've seen cases where initial denials were overturned simply by resubmitting with properly calculated z-scores and clear documentation that GH levels were normal. The key is ensuring your pediatric endocrinologist explicitly states this is primary, not secondary, IGF-1 deficiency.

FAQ

How long does Humana prior authorization take for Increlex? Standard review takes up to 30 days. Expedited review (when delay could harm health) takes 72 hours. Contact Humana HCPR at 800-555-2546 to check status.

What if Increlex is not on Humana's formulary? You can request a formulary exception with medical necessity documentation. Provide clinical justification for why alternatives are inappropriate.

Can I get an expedited appeal in Illinois? Yes, if delay would seriously jeopardize your health. Expedited external reviews are decided within 72 hours under Illinois law.

Does step therapy apply to Increlex? Typically no, since Increlex is indicated for a specific condition (primary IGF-1 deficiency) where growth hormone therapy is not effective.

What happens if external review overturns the denial? The decision is binding. Humana must immediately approve coverage and cannot appeal the decision.

Are there financial assistance programs? Yes, Ipsen offers patient support programs. Check Increlex.com for current eligibility requirements and applications.

Resources & Next Steps

Getting Increlex covered can be complex, but you don't have to navigate it alone. Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals by analyzing denial letters, plan policies, and clinical notes to draft point-by-point rebuttals aligned with each payer's specific requirements.

Key Contacts

  • Humana Clinical Pharmacy Review: 800-555-2546
  • Illinois Attorney General Health Care Helpline: 1-877-305-5145
  • Illinois Department of Insurance: External Review Process

Official Resources

Next Steps

  1. Gather documentation using the checklist above
  2. Contact your pediatric endocrinologist to initiate prior authorization
  3. Submit complete application to Humana HCPR
  4. Track deadlines for appeals if needed
  5. Know your rights under Illinois external review law

For complex cases or repeated denials, consider working with specialists like Counterforce Health who understand the intricacies of payer-specific workflows and can help ensure your appeal meets all procedural requirements while highlighting the clinical evidence that supports your case.

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage policies and appeal processes may change. Always verify current requirements with your insurance plan and consult with your healthcare provider about treatment decisions. For official guidance on Illinois insurance appeals, contact the Illinois Department of Insurance.

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