By Counterforce Health Team in Photrexa (riboflavin ophthalmic solution) —

How to Get Photrexa Covered by UnitedHealthcare in Ohio: Complete Prior Authorization and Appeals Guide

Answer Box: Getting Photrexa Covered by UnitedHealthcare in Ohio

UnitedHealthcare requires prior authorization for Photrexa (riboflavin ophthalmic solution) corneal cross-linking in Ohio. Coverage is limited to FDA-approved epithelium-off iLink® procedures for progressive keratoconus with documented worsening (≥1 diopter Kmax increase over 12 months). First step: Have your ophthalmologist submit a prior authorization via the UnitedHealthcare Provider Portal with serial topography, pachymetry ≥400 μm, and failed conservative therapy documentation. If denied, you have 180 days for internal appeals and external review through Ohio's Department of Insurance.

Table of Contents

  1. Coverage Requirements at a Glance
  2. Step-by-Step: Fastest Path to Approval
  3. Required Clinical Documentation
  4. Common Denial Reasons & Solutions
  5. Appeals Process in Ohio
  6. Costs and Financial Assistance
  7. When to Escalate to State Regulators
  8. Frequently Asked Questions

Coverage Requirements at a Glance

Requirement What It Means Where to Find It Source
Prior Authorization Required for all Photrexa procedures UnitedHealthcare Provider Portal UHC Ohio PA Requirements
FDA Protocol Only Epithelium-off iLink® system required Medical policy documents UHC Corneal Cross-linking Policy
Progressive Disease ≥1D Kmax increase over 12 months Serial corneal topography Clinical documentation requirements
Minimum Thickness ≥400 μm corneal pachymetry Recent measurement within 30 days FDA safety requirements
In-Network Provider Must use UHC-contracted facility Provider directory UnitedHealthcare member portal
ICD-10 Codes H18.601–H18.609 (keratoconus) Medical coding standards Clinical documentation

Step-by-Step: Fastest Path to Approval

1. Gather Required Documentation (Patient + Clinic)

Timeline: 1-2 weeks

  • Collect serial corneal topography showing progression
  • Obtain recent pachymetry measurement (≥400 μm)
  • Document failed conservative treatments (contact lenses, glasses)
  • Compile visual acuity records showing decline

2. Provider Submits Prior Authorization (Clinic)

Timeline: Same day submission

  • Submit via UnitedHealthcare Provider Portal
  • Include complete medical necessity letter
  • Attach all supporting clinical documentation
  • Use CPT code 0402T and HCPCS J2787

3. UnitedHealthcare Review Process

Timeline: 5-10 business days (standard), 72 hours (urgent)

  • Clinical review by ophthalmology consultant
  • Verification of FDA protocol compliance
  • Assessment of medical necessity criteria

4. Decision Notification

Timeline: Within review period

  • Approval: Procedure can be scheduled
  • Denial: Written notice with specific reasons and appeal instructions

5. Appeal if Denied (Patient + Provider)

Timeline: 180 days from denial

  • Internal appeal through UnitedHealthcare
  • External review via Ohio Department of Insurance if needed
  • Peer-to-peer review option within 60 days

Clinician Corner: Medical Necessity Letter Checklist

Your ophthalmologist's letter should include:

Patient Information:

  • Full name, DOB, member ID
  • Diagnosis: Progressive keratoconus (ICD-10 H18.601-H18.609)
  • Date of initial diagnosis

Clinical Evidence:

  • Serial corneal topography with specific Kmax progression values
  • Best-corrected visual acuity decline documentation
  • Pachymetry measurements confirming ≥400 μm thickness
  • Failed conservative therapy details (contact lens intolerance, inadequate vision correction)

Treatment Justification:

Common Denial Reasons & Solutions

Denial Reason How to Overturn Required Documentation
Insufficient progression evidence Provide clear ≥1D Kmax increase over 12 months Serial topography with dates and measurements
Non-FDA approved protocol Confirm epithelium-off iLink® system use Protocol specifications, equipment verification
Missing conservative therapy trial Document contact lens fitting attempts and outcomes Fitting records, intolerance documentation
Inadequate pachymetry Update with recent measurement ≥400 μm New pachymetry within 30 days of procedure
Out-of-network facility Transfer to UHC-contracted provider Provider directory verification
Experimental/investigational Emphasize FDA-approved status FDA approval documentation, policy references

Appeals Process in Ohio

Internal Appeals (UnitedHealthcare)

Level 1 Internal Appeal

  • Deadline: 180 days from denial
  • Timeline: 30 days for standard review, 72 hours for urgent
  • How to submit: UnitedHealthcare member portal, mail, or fax
  • Required: Denial letter, new clinical evidence, appeal form

Level 2 Internal Appeal

  • Deadline: 60 days from Level 1 denial
  • Timeline: 30 days for review
  • Process: Independent medical reviewer evaluation

External Review (Ohio Department of Insurance)

When available: After exhausting internal appeals for medical necessity denials

Note: Self-funded employer plans are governed by federal ERISA law, but many voluntarily provide external review processes.

Peer-to-Peer Review Option

Available: Within 60 days of denial for treating providers

  • Process: Direct consultation between your ophthalmologist and UHC medical reviewer
  • Timeline: Scheduled within 24 hours of request
  • Outcome: May result in approval or additional documentation requirements

Costs and Financial Assistance

Typical Costs:

  • Complete procedure: $2,500-$4,000 per eye
  • Includes Photrexa solution, facility fees, and physician charges

Financial Assistance Options:

  • Glaukos Patient Support: Contact manufacturer for potential assistance programs
  • Foundation Grants: Research rare disease foundations supporting keratoconus treatment
  • Payment Plans: Many facilities offer structured payment options
  • HSA/FSA: Eligible expense for health savings accounts
Tip: If UnitedHealthcare covers the procedure, your out-of-pocket cost depends on your specific plan's deductible, copay, and coinsurance structure.

When to Escalate to State Regulators

Contact the Ohio Department of Insurance if:

  • UnitedHealthcare improperly denies external review eligibility
  • Appeal deadlines are not met by the insurer
  • You suspect violations of Ohio insurance law
  • Consumer Services Division: 1-800-686-1526
  • Online complaint form: Available on ODI website

For additional consumer assistance, UHCAN Ohio (Universal Health Care Action Network) provides advocacy support and can help navigate complex appeals.

From Our Advocates

"We've seen several Ohio patients successfully overturn initial Photrexa denials by providing more detailed progression documentation. One case involved resubmitting with topography reports that clearly showed the 6-month and 12-month Kmax changes side-by-side, rather than just the most recent values. The peer-to-peer review was particularly helpful when the ophthalmologist could directly explain why contact lenses were contraindicated due to the patient's specific corneal shape changes. This is a composite example based on common successful strategies, not a guarantee of outcomes."

Frequently Asked Questions

How long does UnitedHealthcare prior authorization take in Ohio? Standard reviews take 5-10 business days. Urgent cases (where delay could harm your health) are reviewed within 72 hours. Submit urgent requests with clear documentation of medical urgency.

What if Photrexa is not on UnitedHealthcare's formulary? Photrexa requires prior authorization regardless of formulary status. The FDA-approved iLink® protocol is generally covered when medical necessity criteria are met, even if not on standard formulary.

Can I request expedited appeal if my keratoconus is progressing rapidly? Yes. Document rapid progression with recent topography and vision changes. Both internal appeals and Ohio external reviews offer expedited timelines for urgent medical situations.

Does step therapy apply to corneal cross-linking? UnitedHealthcare typically requires documentation of failed conservative treatments (contact lenses, glasses) before approving cross-linking, which functions similarly to step therapy requirements.

What happens if I use an out-of-network provider? UnitedHealthcare generally won't cover out-of-network Photrexa procedures unless you obtain prior approval for a network adequacy exception. This requires demonstrating no qualified in-network providers are available.

How do I find UnitedHealthcare-contracted ophthalmologists in Ohio? Use the provider directory on your UnitedHealthcare member portal or call member services. Ensure the provider is specifically credentialed for corneal procedures and has iLink® system access.

Can I appeal a denial even if I haven't had the procedure yet? Yes. Prior authorization denials can be appealed immediately. Don't wait to have the procedure before starting the appeals process, as this could result in significant out-of-pocket costs.

What if my employer plan is self-funded? Self-funded plans follow federal ERISA rules rather than Ohio state insurance law. However, many provide similar appeal processes voluntarily. Check your plan documents or contact HR for specific procedures.

Counterforce Health specializes in helping patients navigate complex prior authorization and appeals processes for specialty medications and procedures. Their platform analyzes denial letters and creates targeted, evidence-backed appeals that align with specific payer requirements, potentially saving patients and providers significant time in the approval process.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage varies by individual plan. Always consult with your healthcare provider and insurance company for guidance specific to your situation. For official Ohio insurance regulations and consumer rights, visit the Ohio Department of Insurance website.

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