By Counterforce Health Team in Natpara (parathyroid hormone) —

How to Get Natpara (Parathyroid Hormone) Covered by Humana in New York: Appeals Guide for Discontinued Drug

Answer Box: Natpara Coverage Status

Natpara (parathyroid hormone) is permanently discontinued as of December 31, 2025. Humana automatically denies new Natpara prescriptions because there's no commercial supply. Instead, focus on getting alternative treatments covered like optimized calcium/calcitriol or Yorvipath. For Humana Medicare denials in New York, you have 65 days to file an appeal using Medicare's federal process (not NY State external appeals). Start by requesting a peer-to-peer review with your endocrinologist while preparing your formal appeal.

First step today: Call the number on your denial letter to request a peer-to-peer discussion between your doctor and Humana's medical reviewer.

Table of Contents

  1. Understanding Natpara's Discontinuation
  2. Reading Your Humana Denial Letter
  3. Alternative Treatments to Request Coverage For
  4. Humana Appeal Process in New York
  5. Medical Necessity Documentation
  6. Peer-to-Peer Review Strategy
  7. External Appeals: Medicare vs. New York State
  8. Appeal Templates and Scripts
  9. When Appeals Fail: Next Steps
  10. FAQ

Understanding Natpara's Discontinuation

Takeda discontinued Natpara manufacturing globally at the end of 2024, and the U.S. Special Use Program ends December 31, 2025. No new Natpara prescriptions can be filled after this date, regardless of insurance coverage.

This means:

  • New denial appeals for Natpara itself are futile — there's simply no drug to dispense
  • Focus your efforts on alternative treatments for hypoparathyroidism
  • Existing Natpara patients must transition to other therapies before the program ends
Note: All unused Natpara cartridges must be returned by January 31, 2026 per FDA requirements.

Reading Your Humana Denial Letter

Your denial letter contains critical information for your appeal strategy. Look for:

Key Elements to Extract

Element What to Look For Why It Matters
Denial reason "Not medically necessary," "Non-formulary," "Step therapy required" Determines your rebuttal strategy
Appeal deadline Usually 65 days from denial date Miss this and you lose appeal rights
Plan type Medicare Advantage, Part D, or commercial Different appeal processes apply
Contact information Phone, fax, portal for appeals Where to submit your appeal

Common Denial Codes for Natpara

  • Drug not available: Reflects discontinuation status
  • Non-formulary: Not on Humana's approved drug list
  • Prior authorization required: Need pre-approval with clinical documentation
  • Step therapy: Must try other treatments first

Alternative Treatments to Request Coverage For

Since Natpara is unavailable, work with your endocrinologist to request coverage for these alternatives:

Primary Standard of Care

  • Calcium supplements (calcium carbonate or citrate): 1-3g elemental calcium daily
  • Calcitriol (active vitamin D): 0.25-2+ µg daily, divided doses
  • Cholecalciferol (vitamin D3): 800-2000 IU daily for vitamin D sufficiency

Advanced Alternative: Yorvipath

Yorvipath is now the preferred PTH analog alternative to Natpara for patients who fail conventional therapy. Coverage requires:

  • Confirmed chronic hypoparathyroidism diagnosis
  • Failed/inadequate response to optimized calcium + calcitriol
  • Endocrinologist prescribing
  • Regular monitoring protocol

Humana Appeal Process in New York

Medicare vs. Commercial Plans

If you have Humana Medicare (Advantage or Part D):

  • Use federal Medicare appeals process
  • 65-day deadline from denial date
  • Not eligible for NY State external appeals

If you have commercial Humana:

  • May be eligible for NY State external appeals through DFS
  • Must complete internal appeal first

Humana Medicare Appeal Timeline

Level Timeframe Decision Authority
Level 1: Plan Appeal 7 days (Part D), 30-60 days (Part C) Humana
Level 2: Independent Review 7 days (Part D), 30 days (Part C) Medicare IRE
Level 3: ALJ Hearing 90 days Administrative Law Judge

Source: Humana Member Appeals Process

How to File Your Appeal

  1. Gather required information:
    • Member ID and claim details
    • Clear statement this is an "appeal" or "redetermination"
    • Clinical documentation supporting medical necessity
  2. Submit via methods listed on denial letter:
    • Mail to Humana Grievances & Appeals address
    • Fax (for provider appeals)
    • Online portal (verify current link)
  3. Request expedited review if urgent:
    • Standard: 7 days for Part D decisions
    • Expedited: 72 hours if delay could seriously jeopardize health

Medical Necessity Documentation

Essential Elements for Alternative Therapy Appeals

Your endocrinologist should include:

Diagnosis Documentation:

  • ICD-10 codes for chronic hypoparathyroidism (E20.x)
  • Laboratory evidence: low/inappropriate PTH, chronic hypocalcemia
  • Etiology (post-surgical, autoimmune, genetic)

Treatment History:

  • Failed conventional therapy details:
    • Calcium doses tried (mg elemental calcium daily)
    • Calcitriol doses and duration
    • Reasons for inadequacy (persistent symptoms, hypercalciuria, kidney issues)
  • Clinical consequences without adequate treatment:
    • ER visits for hypocalcemia
    • Functional impairment
    • Quality of life impacts

Current Clinical Status:

  • Recent labs (calcium, phosphate, magnesium, creatinine)
  • 24-hour urine calcium if available
  • Symptom severity and frequency
Clinician Corner: Include specific failed dosing regimens (e.g., "Patient required 3g elemental calcium plus 2µg calcitriol daily but developed hypercalciuria >400mg/24hrs and declining eGFR") rather than vague statements about treatment failure.

Peer-to-Peer Review Strategy

Requesting the Call

Call the number on your denial letter within 5-7 business days to request a peer-to-peer discussion. Your endocrinologist (not office staff) must participate.

Preparation Checklist

Before the call, your doctor should review:

Key Talking Points

  1. Establish medical necessity: "This patient has confirmed chronic hypoparathyroidism with [specific lab values] requiring hormone replacement therapy"
  2. Document treatment failures: "We optimized conventional therapy to [specific doses] over [timeframe] but patient continued to experience [specific symptoms/complications]"
  3. Justify alternative therapy: "Given Natpara's discontinuation, [Yorvipath/intensive conventional therapy] represents the appropriate next step per [relevant guidelines]"

External Appeals: Medicare vs. New York State

Important Distinction

Medicare beneficiaries cannot use NY State external appeals. New York's Department of Financial Services external appeal process does not apply to Medicare or Medicare Advantage plans.

For Humana Medicare Patients

Use the federal Medicare appeals process:

For Commercial Humana Patients

May be eligible for NY State external appeal if:

  • Plan is New York-regulated (not Medicare)
  • Completed internal appeal process
  • Denial based on medical necessity, experimental/investigational, or out-of-network

File within 4 months using NY State External Appeal Application

Appeal Templates and Scripts

Patient Phone Script for Humana

"Hello, I'm calling about a denied prior authorization for [alternative hypoparathyroidism treatment] for member [ID]. The denial was dated [date]. I'd like to request a peer-to-peer review between my endocrinologist and your medical reviewer, and also want to file a formal appeal. Can you help me with both processes?"

Medical Necessity Letter Framework

Opening paragraph: "I am writing to appeal the denial of [specific treatment] for my patient with chronic hypoparathyroidism. This patient requires [treatment] as medically necessary therapy due to inadequate control on conventional treatment and the discontinuation of their previous therapy (Natpara)."

Clinical justification sections:

  1. Diagnosis confirmation (labs, imaging, specialist evaluation)
  2. Treatment history (specific failed regimens with doses/durations)
  3. Medical necessity (current symptoms, complications, functional impairment)
  4. Appropriateness of requested therapy (guideline support, monitoring plan)

Closing: "I respectfully request reconsideration of this denial and approval for [treatment] as medically necessary for this patient's chronic hypoparathyroidism management."

When Appeals Fail: Next Steps

Coverage Alternatives

  1. Manufacturer assistance programs:
    • Check for patient assistance programs for Yorvipath or other alternatives
    • Foundation grants for rare disease treatments
  2. Alternative formulary options:
    • High-dose calcium/calcitriol combinations
    • Thiazide diuretics for hypercalciuria management
    • Magnesium supplementation
  3. Clinical trial enrollment:
    • Research studies for new hypoparathyroidism treatments
    • Contact academic endocrine centers

Regulatory Complaints

If you believe Humana improperly denied medically necessary care:

For Medicare plans:

For commercial plans:

Counterforce Health: Expert Insurance Appeals

Navigating insurance denials for rare disease treatments like hypoparathyroidism therapies requires specialized expertise. Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into targeted, evidence-backed appeals. The platform analyzes denial letters, identifies specific denial reasons, and drafts point-by-point rebuttals aligned to each plan's own policies and procedures.

For complex cases involving discontinued drugs like Natpara, Counterforce Health provides the clinical documentation and payer-specific strategies needed to secure coverage for appropriate alternatives, reducing the administrative burden on busy endocrinology practices while improving patient access to essential treatments.

FAQ

Q: How long does a Humana prior authorization appeal take in New York? A: For Medicare Part D: 7 days standard, 72 hours expedited. For Medicare Advantage: 30 days pre-service, 60 days payment appeals. Commercial plans may vary.

Q: Can I still get Natpara covered if I appeal hard enough? A: No. Natpara is permanently discontinued with no commercial supply after December 31, 2025. Focus appeals on alternative treatments.

Q: What if Yorvipath is non-formulary on my Humana plan? A: Request a formulary exception with medical necessity documentation. Your endocrinologist must demonstrate failed conventional therapy and need for PTH analog treatment.

Q: Does New York's external appeal process help with Humana Medicare denials? A: No. Medicare beneficiaries must use the federal Medicare appeals process, not NY State external appeals through DFS.

Q: How do I prove medical necessity for expensive hypoparathyroidism treatments? A: Document specific failed conventional therapy regimens (doses, duration, side effects), current symptoms/complications, and functional impairment. Include recent labs and specialist evaluation.

Q: What's the difference between a coverage determination and an appeal? A: A coverage determination is the initial request for coverage. An appeal challenges a denial of that initial request.

Q: Can I request an expedited appeal for hypoparathyroidism treatments? A: Yes, if delaying treatment could seriously jeopardize your health. Provide documentation of urgent clinical need.

Q: What happens if I miss the 65-day appeal deadline? A: You generally lose appeal rights unless you can provide a valid reason for late filing. Don't risk it—file promptly.

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 decisions. Appeal processes and coverage policies may change; verify current requirements with your insurer and relevant regulatory agencies.

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