By Counterforce Health Team in Lumizyme (alglucosidase alfa) —

How to Get Lumizyme (Alglucosidase Alfa) Covered by Humana in Illinois: Coding, Prior Authorization, and Appeals Guide

Quick Answer: Getting Lumizyme Covered by Humana in Illinois

Lumizyme (alglucosidase alfa) requires prior authorization from Humana and must be prescribed by a specialist familiar with Pompe disease. Use ICD-10 code E74.02 for billing, and ensure your doctor submits comprehensive documentation including enzyme testing results and genetic confirmation. If denied, you have 65 days to appeal internally, then 30 days for external review through Illinois's independent process. Start by having your physician call Humana at 1-866-488-5995 to initiate prior authorization.

First step today: Contact your prescribing physician to ensure they have your complete Pompe disease diagnostic workup, including GAA enzyme levels and genetic testing results.

Table of Contents

  1. Coding Basics: Medical vs. Pharmacy Benefit Paths
  2. ICD-10 Mapping and Documentation Requirements
  3. Product Coding: HCPCS, Units, and Billing
  4. Clean Prior Authorization Request Anatomy
  5. Common Pitfalls and How to Avoid Them
  6. Verification Steps with Humana Resources
  7. Appeals Process in Illinois
  8. Quick Audit Checklist
  9. FAQ

Coding Basics: Medical vs. Pharmacy Benefit Paths

Lumizyme falls under Medicare Part B coverage when administered as an infusion in a clinical setting. This means it's billed as a medical benefit, not through your prescription drug plan. Lumizyme is generally covered by Medicare Part B when administered and billed as incident to a physician's services.

Key Coverage Points:

  • Medicare pays 80% of the allowable amount (Average Sales Price plus 6%)
  • You're responsible for 20% coinsurance
  • 2025 Part B deductible: $257 per year
  • Hospital outpatient coinsurance is limited to the Part A deductible amount
Note: Humana Medicare Advantage plans must cover services that Original Medicare covers, but they may have different prior authorization requirements.

ICD-10 Mapping and Documentation Requirements

Primary Diagnosis Code: E74.02 - Pompe disease (acid maltase deficiency)

This code falls under endocrine, nutritional, and metabolic diseases and should be used for all Pompe disease-related billing. The standard billing code for Pompe disease is E74.02.

Required Clinical Documentation

Your physician must provide comprehensive documentation to support medical necessity:

Diagnostic Confirmation Requirements:

  • GAA enzyme assay showing reduced activity, OR
  • GAA gene sequencing results
  • For infantile-onset: GAA activity less than 1% of normal mean
  • For late-onset: First GAA enzyme assay showing less than 40% of lab-specific normal mean

Clinical Assessment Documentation:

  • Detailed physical examination findings
  • Documentation of organ enlargement (if present)
  • Family history details
  • Respiratory and skeletal muscle weakness documentation
  • For late-onset cases: Forced vital capacity (FVC) results showing 30-79% of predicted value

Product Coding: HCPCS, Units, and Billing

HCPCS Code: J0221 (for alglucosidase alfa)

Dosing and Unit Calculations

Lumizyme is dosed at 20 mg/kg body weight every 2 weeks as an IV infusion. Each vial contains 50 mg of active ingredient.

Calculation Formula:

  • Patient dose (mg) = Patient weight (kg) × 20 mg/kg
  • Number of vials = Patient dose (mg) ÷ 50 mg/vial (round up)

Example: A 68 kg patient requires:

  • 68 kg × 20 mg/kg = 1,360 mg
  • 1,360 mg ÷ 50 mg/vial = 27.2 → 28 vials needed

Billing Units

The recommended dosage results in approximately 46 vials every 14 days for a typical patient, which corresponds to 230 billable units every 14 days.

Clean Prior Authorization Request Anatomy

Essential Components for Humana PA

  1. Patient Demographics
    • Full name, DOB, Humana member ID
    • Contact information
  2. Prescriber Information
    • Physician name, NPI, specialty
    • Office contact details
    • Attestation of medical necessity
  3. Clinical Documentation
    • ICD-10 code E74.02
    • Confirmed Pompe disease diagnosis
    • GAA enzyme testing results
    • Genetic testing confirmation
    • Previous therapy attempts (if any)
    • Dosing justification (20 mg/kg IV q2w)
    • Monitoring plan
  4. Supporting Evidence
    • Lab results showing enzyme deficiency
    • Functional assessment data
    • Pulmonary function tests (for late-onset)

Submission Methods

Phone: 1-866-488-5995 (Humana Provider Services) Online: Humana Provider Portal Fax: (verify current fax number with Humana)

Tip: Your physician can request a peer-to-peer review if the initial request is denied, allowing direct discussion with a Humana medical director.

Common Pitfalls and How to Avoid Them

Pitfall Solution
Incomplete enzyme testing Ensure both GAA enzyme assay AND genetic confirmation are documented
Wrong specialty prescriber Must be prescribed by physician experienced with Pompe disease management
Missing functional assessments Include pulmonary function tests and 6-minute walk test results where applicable
Incorrect unit calculations Double-check weight-based dosing math and vial requirements
Missing monitoring plan Document how treatment response will be assessed and monitored

Documentation Words That Support Coding

When your physician writes clinical notes, these terms strengthen the medical necessity case:

  • "Progressive muscle weakness"
  • "Respiratory insufficiency"
  • "Confirmed GAA deficiency"
  • "Failed conservative management"
  • "Functional decline documented"

Verification Steps with Humana Resources

Before submitting your prior authorization:

  1. Verify Coverage: Check that your Humana plan covers the specific HCPCS code J0221
  2. Confirm Requirements: Review current prior authorization criteria on the Humana Provider Portal
  3. Check Formulary Status: Ensure you understand any formulary restrictions
  4. Validate Submission Method: Confirm current phone numbers and portal access
Important: Lumizyme requires prior authorization from all Humana Medicare Advantage plans.

Appeals Process in Illinois

Internal Appeal Timeline

Deadline: 65 days from Humana's Notice of Denial Humana's Response Time:

  • Pre-service appeals: 30 calendar days
  • Post-service appeals: 60 calendar days
  • Expedited appeals: 72 hours (if delay could harm your health)

External Review Process

If Humana upholds the denial after internal appeal:

Filing Deadline: 30 days after receiving final internal denial (Illinois law also allows up to 4 months) External Reviewer: Maximus Federal Services (Independent Review Entity for Medicare Advantage) Decision Timeline: 7 days for standard appeals, 72 hours for expedited Cost: Free to members Binding Decision: Yes, if overturned, Humana must provide coverage

Illinois Consumer Support

  • Illinois Department of Insurance: 1-877-527-9431
  • Illinois Attorney General Health Care Helpline: 1-877-305-5145

These agencies can provide guidance and advocacy support throughout the appeals process.

Quick Audit Checklist

Before submitting your prior authorization or appeal:

  • ICD-10 code E74.02 documented
  • HCPCS code J0221 verified
  • GAA enzyme testing results included
  • Genetic testing confirmation attached
  • Weight-based dosing calculation verified
  • Prescriber specialty confirmed
  • Medical necessity letter complete
  • Monitoring plan documented
  • Previous therapy attempts noted (if applicable)
  • Contact information current

From Our Advocates "We've seen the strongest approvals when physicians include both the specific GAA enzyme levels and a brief explanation of why the patient needs enzyme replacement therapy now rather than waiting. Humana's medical reviewers appreciate seeing the clinical progression documented clearly."

Counterforce Health: Streamlining Your Appeals Process

If you're facing a denial or need help navigating the prior authorization process, Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals. Their platform analyzes denial letters and plan policies to create point-by-point rebuttals that address specific coverage criteria. For complex cases like Lumizyme, where enzyme testing results and genetic confirmation are crucial, having expert support can significantly improve your chances of approval.

FAQ

Q: How long does Humana prior authorization take for Lumizyme? A: Humana typically processes requests within 30 days for pre-service determinations. Expedited reviews are completed within 72 hours if medically urgent.

Q: What if Lumizyme is not on my Humana formulary? A: You can request a formulary exception based on medical necessity. Your doctor must demonstrate why Lumizyme is medically necessary and why formulary alternatives aren't appropriate.

Q: Can I get coverage while my appeal is pending? A: New Humana enrollees already on Lumizyme may have coverage for the first 90 days while authorization is processed to prevent treatment disruption.

Q: What's Humana's denial rate for prior authorizations? A: Humana's Medicare Advantage denial rate is approximately 3.5%, among the lowest of major insurers. Denials often stem from incomplete documentation rather than medical necessity issues.

Q: Do I need to see a specific type of specialist? A: Yes, Lumizyme should be prescribed by a physician qualified to diagnose and manage Pompe disease, typically a neurologist, geneticist, or metabolic specialist.

Q: What happens if I miss the appeal deadline? A: Illinois has strict timelines - you must file external review within 30 days of final denial. Contact the Illinois Department of Insurance immediately if you've missed a deadline to explore options.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Always consult with your healthcare provider and insurance plan for specific coverage determinations. Requirements and processes may change; verify current information with official sources before taking action.

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