By Counterforce Health Team in Oxervate (cenegermin) —

How to Get Oxervate (cenegermin) Covered by Aetna (CVS Health) in Virginia: Complete Prior Authorization and Appeal Guide

Answer Box: Getting Oxervate Covered by Aetna in Virginia

Aetna (CVS Health) requires prior authorization for Oxervate (cenegermin) for neurotrophic keratitis. You'll need documented stage 2 or 3 disease (ICD-10 codes H16.231-H16.233), failure of artificial tears, and an ophthalmologist's prescription. Submit through CVS Caremark (Aetna's pharmacy benefit manager) using NDC 71923-019-01. If denied, Virginia's State Corporation Commission provides external review within 120 days. Start by calling Aetna member services at 1-800-872-3862 to verify your specific coverage requirements and formulary status.

Table of Contents

  1. Coding Basics: Medical vs. Pharmacy Benefit
  2. ICD-10 Mapping for Neurotrophic Keratitis
  3. Product Coding: NDC, HCPCS, and Billing Units
  4. Clean Prior Authorization Request
  5. Common Coding Pitfalls
  6. Verification with Aetna CVS Health
  7. Appeals Process in Virginia
  8. Quick Audit Checklist
  9. FAQ

Coding Basics: Medical vs. Pharmacy Benefit

Oxervate (cenegermin) typically processes through the pharmacy benefit via CVS Caremark for home administration. However, some plans may cover it under the medical benefit for in-office use.

Pharmacy Benefit Path:

  • Processed through CVS Caremark
  • Uses NDC 71923-019-01
  • Requires prior authorization
  • Home administration by patient/caregiver

Medical Benefit Path:

  • Uses HCPCS code J3590 (unclassified biologics) + NDC
  • Still requires prior authorization
  • In-office or clinical administration
Tip: Call Aetna member services first to confirm which benefit covers Oxervate for your specific plan. This determines your submission pathway and coding requirements.

ICD-10 Mapping for Neurotrophic Keratitis

Proper diagnosis coding is critical for Oxervate approval. Use these specific ICD-10-CM codes:

Code Description Documentation Requirements
H16.231 Neurotrophic keratoconjunctivitis, right eye Stage 2/3 disease, corneal sensitivity testing
H16.232 Neurotrophic keratoconjunctivitis, left eye Epithelial defects, failed conservative therapy
H16.233 Neurotrophic keratoconjunctivitis, bilateral Both eyes affected, bilateral staging
H16.239 Neurotrophic keratoconjunctivitis, unspecified eye Avoid if laterality is known

Documentation must include:

  • Mackie staging (Stage 2: persistent epithelial defect; Stage 3: stromal ulceration)
  • Corneal sensitivity testing results
  • Failed prior treatments (artificial tears, therapeutic contact lenses)
  • Underlying etiology (diabetes, herpes simplex, surgical trauma)

For more detailed coding guidance, Counterforce Health provides specialized support for complex prior authorization submissions, helping clinicians navigate payer-specific requirements and evidence standards.

Product Coding: NDC, HCPCS, and Billing Units

Primary NDC: 71923-019-01 (Oxervate 0.002% ophthalmic solution)

Dosing and Units Calculation:

  • 1 drop per affected eye, 6 times daily for 8 weeks
  • 1 vial per day per eye (each vial = 0.4 mL)
  • Each carton contains 28 vials (1 week supply per eye)
Treatment Scenario Vials Needed Billing Units Cost Estimate
Unilateral (1 eye) 56 vials 56 units ~$118,230
Bilateral (both eyes) 112 vials 112 units ~$236,460
Monthly supply (1 eye) 28 vials 28 units ~$59,115

For Medical Benefit Claims:

  • HCPCS: J3590 (unclassified biologics)
  • Must include NDC 71923-019-01
  • Bill in vials or mL per payer preference

Clean Prior Authorization Request

A successful Aetna prior authorization includes these essential elements:

Required Documentation:

  1. Patient demographics matching insurance card exactly
  2. ICD-10 code (H16.231, H16.232, or H16.233)
  3. Prescriber information (ophthalmologist or optometrist)
  4. Prior therapy failures with specific details:
    • Product name (e.g., "Systane Ultra")
    • Duration tried (minimum 4-6 weeks)
    • Frequency (e.g., "4 times daily")
    • Outcome ("inadequate response, persistent epithelial defect")

Clinical Justification:

  • Stage 2 or 3 neurotrophic keratitis diagnosis
  • Corneal sensitivity test results
  • Visual acuity measurements
  • Treatment goals and monitoring plan

Sample PA Request Language: "Patient has stage 2 neurotrophic keratitis, left eye (H16.232) following herpes simplex keratitis. Failed 6-week trial of Systane Ultra 4x daily with persistent 3mm epithelial defect. Requesting Oxervate 0.002% 1 drop 6x daily for 8 weeks per FDA indication."

Common Coding Pitfalls

Unit Conversion Errors:

  • Billing 28 units for bilateral treatment (should be 112)
  • Missing mL conversion when required (56 vials = 22.4 mL)
  • Exceeding quantity limits without prior authorization

ICD-10 Mismatches:

  • Using dry eye codes (H04.12x) instead of neurotrophic keratitis (H16.23x)
  • Missing laterality specification
  • Incorrect staging documentation

Missing Elements:

  • No NDC on J3590 medical claims
  • Incomplete prior therapy documentation
  • Wrong prescriber specialty (requires ophthalmologist/optometrist)

Benefit Confusion:

  • Submitting medical codes for pharmacy benefit
  • Using pharmacy NDC without required HCPCS for medical benefit
Note: Most Aetna plans limit Oxervate to 56 vials per eye per lifetime. Exceeding this triggers automatic denials requiring detailed clinical justification.

Verification with Aetna CVS Health

Before submitting your prior authorization:

Step 1: Verify Coverage

  • Call Aetna member services: 1-800-872-3862
  • Confirm medical vs. pharmacy benefit
  • Check formulary tier and restrictions

Step 2: Check CVS Caremark Requirements

  • Log into provider portal at cvs.com
  • Review current prior authorization criteria
  • Verify NDC and quantity limits

Step 3: Confirm Submission Method

  • Electronic submission preferred
  • Fax backup: (verify current number with CVS Caremark)
  • Include all required attachments

Step 4: Timeline Expectations

  • Standard decision: 72 hours to 5 business days
  • Expedited (urgent): 24-72 hours
  • Complex cases may take up to 15 days

Appeals Process in Virginia

If Aetna denies your Oxervate prior authorization, Virginia provides robust appeal rights through the State Corporation Commission (SCC).

Internal Appeals (First Step):

  • File within 180 days of denial notice
  • Submit through Aetna member portal or by phone
  • Include additional clinical documentation
  • Decision within 30 days (expedited: 72 hours for urgent cases)

External Review (If Internal Appeals Fail): Virginia's SCC Bureau of Insurance offers independent external review:

Eligibility:

  • Final adverse determination from Aetna
  • Based on medical necessity, appropriateness, or effectiveness
  • Virginia-issued plan or opted-in self-funded plan

Timeline and Process:

  • File within 120 days of final denial
  • Use Form 216-A (available at scc.virginia.gov)
  • Submit via:

External Review Timeline:

  • SCC sends copy to Aetna: 1 business day
  • Aetna eligibility review: 5 business days
  • Independent Review Organization (IRO) assignment: 1 business day
  • Final IRO decision: 45 days maximum

Special Provisions:

  • Cancer treatment denials: No internal appeal exhaustion required
  • Expedited external review: 72 hours for urgent cases
  • IRO decision is binding on Aetna

For complex appeals involving specialty drugs like Oxervate, Counterforce Health specializes in crafting evidence-based appeals that address specific payer denial reasons with targeted clinical and regulatory citations.

Quick Audit Checklist

Before submitting your Oxervate prior authorization to Aetna:

Patient Information:

  • Demographics match insurance card exactly
  • Correct member ID and group number
  • Current contact information

Clinical Documentation:

  • ICD-10 code H16.231, H16.232, or H16.233
  • Stage 2 or 3 neurotrophic keratitis documented
  • Corneal sensitivity testing results included
  • Prior therapy failures detailed with specific products, duration, outcomes

Prescriber Requirements:

  • Ophthalmologist or optometrist prescription
  • Provider NPI number included
  • DEA number if required

Coding Accuracy:

  • NDC 71923-019-01 for pharmacy benefit
  • HCPCS J3590 + NDC for medical benefit
  • Correct quantity (56 vials unilateral, 112 bilateral)
  • Appropriate units (vials vs. mL per payer preference)

Supporting Documents:

  • Clinical notes with staging
  • Prior authorization form completed
  • Denial letters if resubmitting
  • Patient consent forms

FAQ

How long does Aetna prior authorization take for Oxervate? Standard decisions typically take 72 hours to 5 business days. Expedited reviews for urgent cases are completed within 24-72 hours.

What if Oxervate is non-formulary on my Aetna plan? You can request a formulary exception with clinical justification. Document medical necessity and lack of suitable formulary alternatives.

Can I request an expedited appeal in Virginia? Yes, if your doctor certifies that waiting could seriously jeopardize your health. Expedited external reviews are decided within 72 hours.

Does step therapy apply to Oxervate with Aetna? Most plans require documented failure of artificial tears before approving Oxervate. No broader step therapy to other neurotrophic agents is typically required.

What's the difference between CVS Caremark and Aetna coverage? CVS Caremark is Aetna's pharmacy benefit manager. Most Oxervate prescriptions process through CVS Caremark's pharmacy benefit rather than Aetna's medical benefit.

How much does Oxervate cost without insurance? Approximately $2,111 per vial, with a full 8-week unilateral course costing around $118,230. Manufacturer assistance programs may be available.

What happens if my external review is denied in Virginia? The IRO decision is final and binding. You retain rights to pursue legal action separately, but the insurance company is not required to cover the treatment.

Can I get help with my Oxervate appeal in Virginia? Yes, Virginia's Managed Care Ombudsman (1-877-310-6560) can assist with understanding appeal rights and may help resolve issues informally.

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 plan terms and clinical circumstances. Always consult with your healthcare provider and insurance company for specific coverage questions. For assistance with complex prior authorization and appeal processes, contact Counterforce Health or Virginia's Bureau of Insurance Consumer Services at 1-877-310-6560.

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