By Counterforce Health Team in Nourianz (istradefylline) —

How to Get Nourianz (istradefylline) Covered by Humana in Michigan: Complete PA Guide with Appeals Process

Answer Box: Getting Nourianz Covered by Humana in Michigan

Nourianz (istradefylline) requires prior authorization from Humana Medicare plans in Michigan. Most approvals require: confirmed Parkinson's diagnosis (ICD-10 G20.A2/G20.B2), stable carbidopa/levodopa therapy for ≥1 year, and documented ≥2 hours daily OFF episodes. Submit via Humana's provider portal with OFF-time diary and neurologist letter. Standard decisions within 7 days; expedited within 72 hours if health jeopardized. If denied, appeal within 65 days using Humana's redetermination form, then escalate to Michigan DIFS external review within 127 days.

Table of Contents

  1. Coverage Requirements at a Glance
  2. Step-by-Step: Fastest Path to Approval
  3. ICD-10 Coding for Parkinson's OFF Episodes
  4. Prior Authorization Documentation
  5. Common Denial Reasons & Solutions
  6. Appeals Process: Humana to Michigan DIFS
  7. Cost-Saving Programs
  8. FAQ

Coverage Requirements at a Glance

Requirement Details Where to Verify Source
Prior Authorization Required for most Humana Medicare plans MyHumana portal drug lookup Humana PA Search Tool
Formulary Status Typically Tier 4-5 specialty Plan-specific formulary PDF Humana Drug Lists
Age Requirement 18+ years FDA prescribing information Nourianz Prescribing Info
Diagnosis Parkinson's disease with OFF episodes ICD-10 G20.A2 or G20.B2 CDC ICD-10 Tool
Concurrent Therapy Stable carbidopa/levodopa ≥1 year Clinical documentation Humana PA Requirements
OFF Episode Documentation ≥2 hours daily, diary preferred Patient logs, neurologist notes PrescriberPoint PA Forms

Step-by-Step: Fastest Path to Approval

1. Verify Coverage and Requirements

Who: Patient or clinic staff
Action: Log into MyHumana portal and search "istradefylline" or "Nourianz" to confirm PA requirement and tier status.
Timeline: 5-10 minutes

2. Gather Clinical Documentation

Who: Patient and prescribing physician
Required documents:

  • Parkinson's diagnosis confirmation with ICD-10 code
  • Current carbidopa/levodopa regimen (dose, duration)
  • OFF-time diary (1-2 weeks minimum)
  • Previous medication trials and outcomes
  • Neurologist consultation notes

Timeline: 1-2 weeks for diary completion

3. Complete Prior Authorization Form

Who: Prescribing physician or clinic staff
Action: Submit via Humana provider portal or download general PA form for fax submission.
Timeline: Same day submission possible

4. Submit Supporting Documentation

Who: Physician
Include: Medical necessity letter, OFF-time diary, lab results, imaging if relevant
Method: Provider portal upload or fax to number on PA form

5. Track Decision

Who: Patient and clinic
Standard timeline: 7 calendar days
Expedited: 72 hours (requires physician attestation of health risk)
Check status: Humana provider portal or call number on member ID card

6. If Denied, File Appeal Immediately

Who: Patient, physician, or authorized representative
Deadline: 65 days from denial notice
Method: Humana redetermination form online, mail, or fax

7. Escalate to Michigan External Review if Needed

Who: Patient
Deadline: 127 days after Humana final denial
Contact: Michigan DIFS at (877) 999-6442 or online external review form

ICD-10 Coding for Parkinson's OFF Episodes

Accurate diagnosis coding is crucial for Nourianz approval. The 2024 ICD-10-CM updates provide specific codes for motor fluctuations:

ICD-10 Code Description Use When
G20.A2 Parkinson's disease without dyskinesia, with fluctuations Patient has OFF episodes but no involuntary movements
G20.B2 Parkinson's disease with dyskinesia, with fluctuations Patient has both OFF episodes and dyskinesia
G20.A1 Parkinson's disease without dyskinesia, without fluctuations Not appropriate for Nourianz PA
G20.B1 Parkinson's disease with dyskinesia, without fluctuations Not appropriate for Nourianz PA
Clinician Note: Document OFF episodes explicitly in clinical notes using terms like "motor fluctuations," "wearing-off phenomena," or "end-of-dose deterioration" to support G20.A2/G20.B2 coding. Source: Practical Neurology ICD-10 Coding Guide

Prior Authorization Documentation

Medical Necessity Letter Template

Your physician's letter should address these key points:

  1. Patient Demographics & Diagnosis
    • Age, confirmed Parkinson's diagnosis date
    • ICD-10 code (G20.A2 or G20.B2)
    • Prescribing neurologist credentials
  2. Current Treatment History
    • Carbidopa/levodopa dose and duration (minimum 1 year)
    • Previous adjunct therapies tried and failed:
      • Amantadine (common first-line adjunct)
      • COMT inhibitors (entacapone, opicapone)
      • MAO-B inhibitors (rasagiline, safinamide)
    • Reasons for discontinuation (ineffective, intolerable side effects)
  3. OFF Episode Documentation
    • Frequency: hours per day experiencing OFF time
    • Symptoms during OFF periods (bradykinesia, rigidity, tremor)
    • Impact on daily activities and quality of life
    • Attach OFF-time diary showing patterns
  4. Clinical Rationale for Nourianz
    • Mechanism of action (adenosine A2A receptor antagonist)
    • Expected benefit based on clinical trials
    • Dosing plan (typically 20mg daily, may increase to 40mg)

OFF-Time Diary Requirements

Patients should track for 1-2 weeks minimum:

  • Time of each carbidopa/levodopa dose
  • Onset and duration of OFF periods
  • Specific symptoms during OFF time
  • Activities affected (walking, dressing, eating)
From Our Advocates: We've seen faster approvals when patients submit detailed OFF-time diaries showing clear patterns. One composite case involved a Michigan patient whose initial PA was denied for "insufficient documentation," but approval came within 48 hours after submitting a two-week diary showing 3-4 hours of daily OFF time affecting basic activities.

Common Denial Reasons & Solutions

Denial Reason Solution Required Documentation
Insufficient OFF episode documentation Submit detailed OFF-time diary 1-2 weeks of hourly symptom tracking
Step therapy not completed Document failed trials of preferred agents Prescription records, physician notes on amantadine, COMT/MAO-B inhibitors
Not prescribed by neurologist Obtain neurologist consultation Specialist evaluation and prescription
Inadequate levodopa trial duration Demonstrate ≥1 year stable therapy Pharmacy records, prescription history
Missing concurrent levodopa therapy Confirm current carbidopa/levodopa use Current prescription, dosing schedule

Appeals Process: Humana to Michigan DIFS

Level 1: Humana Redetermination

  • Deadline: 65 days from denial notice
  • Timeline: 7 days standard, 72 hours expedited
  • Submit: Humana appeals form online, mail, or fax
  • Required: Original denial letter, additional clinical evidence, physician letter

Level 2: Independent Review Organization

  • Deadline: 65 days from Humana redetermination denial
  • Timeline: Up to 60 days
  • Process: Automatic escalation through Medicare system
  • Contact: Information provided in Humana denial letter

Michigan External Review (State Level)

For non-Medicare Humana plans or additional state protections:

  • Deadline: 127 days from final internal appeal denial
  • Contact: Michigan DIFS at (877) 999-6442
  • Submit: Online external review form or mail/fax
  • Timeline: 60 days standard, 72 hours expedited
  • Cost: Free to consumers
Note: Michigan's 127-day external review deadline is longer than the federal 120-day standard, providing extra time for appeals. Source: Michigan Patient's Right to Independent Review Act

Cost-Saving Programs

Manufacturer Support

  • Kyowa Kirin Patient Assistance: Income-based free drug program
  • Commercial copay card: May reduce costs to $10-$25/month for eligible patients
  • Verify eligibility: Nourianz.com patient resources (verify current programs)

Foundation Grants

  • PAN Foundation: Parkinson's disease fund for medication assistance
  • Patient Access Network: Specialty drug coverage
  • Application: Online applications typically require income documentation

Counterforce Health helps patients navigate insurance denials by analyzing denial letters, identifying specific coverage gaps, and drafting targeted appeals that address payers' exact requirements. Their platform streamlines the appeals process by matching clinical evidence to payer policies, potentially reducing the time from denial to approval.

FAQ

How long does Humana prior authorization take for Nourianz in Michigan?

Standard PA decisions are issued within 7 calendar days. Expedited reviews (when delay could harm health) are decided within 72 hours. Source: Humana PA Process

What if Nourianz is non-formulary on my Humana plan?

Non-formulary drugs can still be covered through formulary exceptions. Submit the same PA documentation emphasizing medical necessity and failed trials of formulary alternatives.

Can I request an expedited appeal if my symptoms worsen?

Yes. Expedited appeals require a physician's written statement that delay would seriously jeopardize your health or ability to function. Decisions must be made within 72 hours.

Does step therapy apply if I tried medications outside Michigan?

Yes. Document all previous therapies regardless of location. Include prescription records and physician notes explaining why each treatment failed or caused intolerable side effects.

What happens if I miss the 65-day appeal deadline?

Humana may accept late appeals for "good cause" such as serious illness or failure to receive proper notice. Contact Humana member services immediately to request an extension.

How much does Nourianz cost without insurance in Michigan?

Cash pricing approximates $1,900-$2,100 per 30 tablets. Manufacturer copay programs and patient assistance may significantly reduce costs for eligible patients.

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage policies and appeal processes may vary by specific plan. Always verify current requirements with your Humana plan and consult healthcare providers for medical decisions.

Sources & Further Reading

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