By Counterforce Health Team in Nourianz (istradefylline) —

How to Get Nourianz (istradefylline) Covered by Humana in Pennsylvania: Complete Prior Authorization and Appeals Guide

Answer Box: Getting Nourianz (istradefylline) Covered by Humana in Pennsylvania

Nourianz requires prior authorization from Humana Medicare Advantage and Part D plans in Pennsylvania. The fastest path to approval: (1) Ensure your neurologist documents stable carbidopa/levodopa therapy with OFF episodes using ICD-10 code G20.A2 or G20.B2, (2) Complete step therapy with MAO-B inhibitors or COMT inhibitors (or document contraindications), and (3) Submit the PA request via Humana's provider portal with medical necessity documentation. If denied, you have 65 days to file an internal appeal, then proceed through Medicare's federal appeal process (Pennsylvania's state external review doesn't apply to Medicare plans).

Table of Contents

  1. Coverage Requirements at a Glance
  2. Step-by-Step: Fastest Path to Approval
  3. Coding and Documentation Essentials
  4. Common Denial Reasons and How to Fix Them
  5. Appeals Process for Humana Medicare in Pennsylvania
  6. Cost Savings and Patient Support
  7. Frequently Asked Questions

Coverage Requirements at a Glance

Requirement Details Documentation Needed Source
Prior Authorization Required for all Humana Medicare plans PA form via provider portal Humana PA Lists
Diagnosis Code G20.A2 (PD with OFF episodes, no dyskinesia) or G20.B2 (PD with OFF episodes and dyskinesia) Clinical notes documenting motor fluctuations ICD-10 Coding Guidelines
Concurrent Therapy Stable carbidopa/levodopa for ≥1 year Prescription history and clinical notes Nourianz Prescribing Information
Step Therapy Trial/contraindication of MAO-B inhibitors or COMT inhibitors Prior therapy records or contraindication letter Humana PA Search Tool
Prescriber Neurologist or movement disorder specialist preferred Provider credentials Standard PA requirement
Appeal Deadline 65 days from denial notice Denial letter with date Medicare Appeals Process

Step-by-Step: Fastest Path to Approval

1. Verify Current Coverage Status

Who: Patient or clinic staff
Action: Call the Humana member services number on your insurance card to confirm your specific plan type (Medicare Advantage vs. Part D) and current formulary status for Nourianz.
Timeline: Same day
Source: Humana Member Portal

2. Gather Required Documentation

Who: Prescribing neurologist
Documents needed:

  • Clinical notes documenting Parkinson's diagnosis with OFF episodes
  • Prescription history showing stable carbidopa/levodopa therapy
  • Records of prior MAO-B inhibitor or COMT inhibitor trials (or contraindication letter)
  • OFF-time diary or clinical assessment of motor fluctuations Timeline: 1-2 business days

3. Ensure Proper ICD-10 Coding

Who: Clinic coding staff
Action: Use G20.A2 (Parkinson's disease without dyskinesia, with fluctuations) or G20.B2 (Parkinson's disease with dyskinesia, with fluctuations) to accurately reflect OFF episodes.
Source: ICD-10 Coding for Parkinson's

4. Submit Prior Authorization Request

Who: Prescriber or authorized clinic staff
Method: Electronic submission via Humana provider portal (fastest) or fax to number on PA form
Timeline: Standard decision within 7 days; expedited within 72 hours if urgent
Source: Humana PA Process

5. Follow Up on Decision

Who: Patient or clinic
Action: Check portal or call member services for status updates. If approved, coordinate with specialty pharmacy for fulfillment.
Timeline: Monitor daily after submission

Coding and Documentation Essentials

ICD-10 Codes for Parkinson's with OFF Episodes

The 2023+ expanded G20 codes specifically capture motor fluctuations critical for Nourianz approval:

  • G20.A2: Parkinson's disease without dyskinesia, with fluctuations - Use when patient has OFF episodes but no involuntary movements during ON time
  • G20.B2: Parkinson's disease with dyskinesia, with fluctuations - Use when patient has both OFF episodes and mild dyskinesia
Clinician Corner: Documentation must explicitly mention "OFF episodes," "motor fluctuations," or "wearing-off" phenomena. Avoid vague terms like "variable response." Include specific timing (e.g., "experiences 3-4 hours of OFF time daily despite optimized levodopa dosing").

NDC and Billing Information

Nourianz NDC: Verify current manufacturer NDC at Nourianz.com as codes may change.
No HCPCS J-Code: As an oral medication, Nourianz uses NDC billing rather than injection codes.
Pharmacy Benefit: Billed through Part D with standard quantity and days' supply information.

Medical Necessity Documentation Checklist

Your neurologist's PA letter should include:

  • ✅ Confirmed Parkinson's diagnosis with ICD-10 code
  • ✅ Duration and stability of current carbidopa/levodopa regimen
  • ✅ Frequency and impact of OFF episodes on daily function
  • ✅ Prior trials of MAO-B inhibitors (rasagiline, selegiline, safinamide) or COMT inhibitors (entacapone, opicapone, tolcapone)
  • ✅ Contraindications to step therapy drugs (if applicable)
  • ✅ Treatment goals and expected outcomes with Nourianz

Common Denial Reasons and How to Fix Them

Denial Reason Fix Strategy Required Documentation
Incomplete step therapy Document trials of MAO-B inhibitors or COMT inhibitors, or provide contraindication letter Prescription records showing adequate trials or clinical notes explaining contraindications
Inadequate OFF-time documentation Submit detailed clinical assessment or patient diary OFF-episode frequency, duration, and functional impact documentation
Non-formulary status Request formulary exception with comparative effectiveness data Medical necessity letter citing Parkinson's guidelines and patient-specific factors
Quantity limit exceeded Justify higher dosing based on patient factors Document smoking status (40mg for heavy smokers), metabolism, or drug interactions
Missing levodopa therapy proof Provide prescription history and current regimen details Pharmacy records and clinical notes showing stable carbidopa/levodopa therapy
From our advocates: We've seen denials overturned when neurologists explicitly state why first-line adjuncts failed or were contraindicated. A simple statement like "Patient experienced hallucinations with rasagiline trial in 2023" can satisfy step therapy requirements without additional medication trials.

Appeals Process for Humana Medicare in Pennsylvania

Important: Pennsylvania's Independent External Review process does not apply to Medicare plans like Humana Medicare. Medicare appeals follow federal CMS procedures.

Internal Appeal (Level 1)

  • Deadline: 65 days from denial notice
  • Method: Submit via Humana member portal or call member services
  • Timeline: Standard reconsideration within 60 days
  • Required: Original PA documents plus any additional supporting evidence

Medicare Reconsideration (Level 2)

  • When: After internal appeal denial
  • Deadline: 60 days from Level 1 decision
  • Process: Independent review organization evaluates case
  • Expedited option: Available for urgent medical needs

Higher Appeal Levels

If Level 2 is denied and the dollar amount meets thresholds, you can proceed to:

  • Administrative Law Judge hearing
  • Medicare Appeals Council review
  • Federal district court (for high-value claims)

Source: Medicare Appeals Process

Cost Savings and Patient Support

Manufacturer Support Programs

  • Copay assistance: Eligible commercially insured patients may pay as little as $20 per month
  • Patient support: Available through Nourianz Patient Support
  • Specialty pharmacy coordination: Automatic application of savings programs

Additional Resources

  • Medicare Extra Help: Low-income subsidy program for Part D premiums and copays
  • Pennsylvania PACE: State pharmaceutical assistance for seniors (verify eligibility at pa.gov)
  • Foundation grants: Patient advocacy organizations may provide emergency assistance

At approximately $1,900-$2,100 per month without insurance, these programs can significantly reduce out-of-pocket costs while appeals are pending.

Frequently Asked Questions

Q: How long does Humana prior authorization take for Nourianz in Pennsylvania?
A: Standard PA decisions are made within 7 calendar days. Expedited reviews for urgent medical needs are completed within 72 hours.

Q: What if Nourianz is not on my Humana formulary?
A: Request a formulary exception by submitting medical necessity documentation showing why formulary alternatives are inappropriate for your specific case.

Q: Can I get an expedited appeal if my Parkinson's symptoms worsen?
A: Yes, Medicare allows expedited appeals when delays could seriously jeopardize your health. Your doctor must certify the urgent need.

Q: Does step therapy apply if I tried these medications in another state?
A: Yes, documented trials from any state count toward step therapy requirements. Provide prescription records and clinical notes from your previous neurologist.

Q: What happens if I miss the 65-day appeal deadline?
A: You may lose your right to appeal that specific denial. However, you can submit a new PA request with additional supporting documentation.

Q: Who can help me navigate the appeals process in Pennsylvania?
A: Contact the Pennsylvania Insurance Department Consumer Services for guidance, though remember that Medicare appeals follow federal rather than state procedures.

Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals for prescription medications like Nourianz. The platform analyzes denial letters, identifies specific rejection reasons, and drafts point-by-point rebuttals using the right clinical evidence and payer-specific requirements. For complex cases involving specialty medications and prior authorization challenges, Counterforce Health helps patients, clinicians, and pharmacies navigate the approval process more effectively.

When facing a Nourianz denial from Humana, having the right documentation strategy can make the difference between approval and prolonged appeals. Counterforce Health's approach of aligning clinical evidence with specific payer policies has helped many patients access necessary Parkinson's treatments through systematic appeal processes.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage decisions depend on individual circumstances, plan details, and medical necessity. Always consult with your healthcare provider and insurance plan directly for coverage determinations. Appeal deadlines and procedures may change; verify current requirements with your insurer.

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