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

How to Get Photrexa (Riboflavin) Covered by Aetna CVS Health in Michigan: Complete Prior Authorization and Appeals Guide

Answer Box: Fast Track to Photrexa Coverage

Aetna CVS Health requires prior authorization for Photrexa (riboflavin ophthalmic solution) corneal cross-linking in Michigan. Key requirements: progressive keratoconus documented by serial Kmax readings (≥1 diopter increase over 12 months), corneal thickness ≥400 microns, and use of FDA-approved iLink system. Submit via Aetna's Availity portal with complete topography records, clinical notes, and ICD-10 codes H18.601-H18.609. If denied, you have 180 days for internal appeal and 127 days for Michigan DIFS external review after final denial.

First step today: Call Aetna member services (number on your ID card) to confirm your specific plan's requirements and download the prior authorization form.

Table of Contents

Coverage Requirements at a Glance

Requirement What It Means Where to Find It Source
Prior Authorization Required before procedure Aetna Availity portal Aetna Precert List
Progressive Keratoconus Kmax increase ≥1 diopter over 12 months Serial corneal topography Counterforce Health Guide
Corneal Thickness ≥400 microns via pachymetry Ophthalmologist measurement FDA labeling requirements
FDA-Approved System iLink (KXL) with Photrexa only Glaukos iLink system Aetna Medical Policy 0681
ICD-10 Codes H18.601-H18.609 for keratoconus Clinical documentation Standard billing requirements
Appeal Deadline 180 days internal, 127 days external Policy documents Michigan DIFS

Step-by-Step: Fastest Path to Approval

1. Confirm Your Diagnosis and Progression (Patient + Doctor)

Your ophthalmologist must document progressive keratoconus with serial corneal topography showing Kmax increase of at least 1 diopter over 12 months. Ensure corneal thickness is ≥400 microns via pachymetry.

Timeline: 1-2 visits over 6-12 months
Documents needed: Baseline and follow-up topography, pachymetry results

2. Verify In-Network Provider (Patient)

Confirm your ophthalmologist and surgical facility accept Aetna and can perform FDA-approved epithelium-off corneal cross-linking with the iLink system.

How to check: Use Aetna's provider directory or call member services
Timeline: Same day

3. Submit Prior Authorization (Doctor's Office)

Your doctor submits the PA request via Aetna's Availity portal with complete clinical documentation, topography records, and medical necessity letter.

Required documents:

  • Completed PA form
  • Serial topography showing progression
  • Clinical notes with diagnosis
  • ICD-10 codes H18.601-H18.609

Timeline: Submit 2+ weeks before procedure
Processing time: 30-45 days standard, 72 hours expedited

4. Review Decision (Patient + Doctor)

Aetna will approve, deny, or request additional information. Approvals typically come with specific conditions about the facility and system used.

What to expect: Written decision via mail and provider portal
Timeline: Within stated processing timeframe

5. Appeal if Denied (Patient + Doctor)

If denied, file internal appeal within 180 days with additional clinical evidence and peer-to-peer review request.

How to file: Aetna member services or provider portal
Timeline: 180 days from denial date

6. External Review if Needed (Patient)

After final internal denial, file with Michigan DIFS within 127 days for independent medical review.

How to file: Michigan DIFS External Review or call 877-999-6442
Timeline: 60 days standard, 72 hours expedited

Clinician Corner: Medical Necessity Documentation

Essential Elements for Approval:Clear diagnosis of progressive keratoconus with ICD-10 codes H18.601-H18.609Serial topography data showing Kmax progression ≥1 diopter over 12 monthsPachymetry confirming corneal thickness ≥400 micronsDocumentation of failed conservative management (glasses, contacts)Confirmation of FDA-approved epithelium-off protocol with iLink systemClinical rationale explaining why cross-linking is medically necessary

Include peer-reviewed references supporting corneal cross-linking efficacy and cite FDA approval status. Aetna's medical policy explicitly covers epithelium-off CXL while excluding epithelium-on as experimental.

Common Denial Reasons & How to Fix Them

Denial Reason How to Overturn Required Documentation
Insufficient progression evidence Submit serial topography with clear Kmax changes Comparative readings 6-12 months apart
Missing pachymetry Provide corneal thickness measurements Current pachymetry showing ≥400 microns
Non-FDA approved system Confirm iLink/Photrexa use only Facility verification of FDA-approved equipment
Lack of medical necessity Enhanced clinical rationale Detailed medical necessity letter with guidelines
Out-of-network facility Change providers or request exception In-network facility confirmation
Pro Tip: Request a peer-to-peer review if initially denied. Many denials are overturned when the reviewing medical director speaks directly with your ophthalmologist about the clinical rationale.

Appeals Process in Michigan

Internal Appeals with Aetna

  • Deadline: 180 days from denial date
  • How to file: Call member services, use online portal, or mail written request
  • Timeline: 30 days for standard review, 72 hours for expedited
  • Required: Original denial letter, additional clinical evidence, medical necessity letter

Michigan External Review

After exhausting internal appeals, Michigan residents can request independent external review through the Department of Insurance and Financial Services (DIFS).

  • Deadline: 127 days from final internal denial
  • How to file: DIFS External Review Form or call 877-999-6442
  • Timeline: 60 days standard, 72 hours expedited (requires physician urgency letter)
  • Cost: Free to consumers
  • Decision: Binding on insurance company
Note: Michigan's 127-day deadline is longer than the federal 120-day standard, giving consumers extra time to prepare their external review request.

Costs and Financial Assistance

Typical Costs: Corneal cross-linking (including Photrexa and facility fees) ranges from $2,500-$4,000 per eye when paid out-of-pocket.

Financial Support Options:

  • Glaukos Patient Assistance: Contact manufacturer for potential support programs
  • National Keratoconus Foundation: Provides resources and potential financial assistance information
  • CareCredit: Medical financing for eye procedures
  • Hospital Financial Aid: Many facilities offer payment plans or charity care programs

Insurance Coverage: Most commercial plans, including Aetna, cover FDA-approved epithelium-off corneal cross-linking when medical necessity criteria are met.

From Our Advocates

We've seen numerous Photrexa appeals succeed in Michigan when patients provided complete progression documentation and worked closely with their ophthalmologist to address Aetna's specific clinical criteria. The key is thorough preparation of the initial prior authorization request—getting it right the first time saves months of appeals. Most denials we encounter stem from incomplete topography records or missing pachymetry data, both easily preventable with proper documentation.

Frequently Asked Questions

How long does Aetna prior authorization take for Photrexa in Michigan? Standard prior authorization decisions take 30-45 days. Expedited reviews (for urgent cases) are completed within 72 hours with appropriate clinical justification.

What if Photrexa is non-formulary on my plan? Photrexa may require formulary exception approval. Your doctor can request this as part of the prior authorization process by demonstrating medical necessity and lack of suitable formulary alternatives.

Can I get expedited appeal review in Michigan? Yes, both Aetna and Michigan DIFS offer expedited reviews (72 hours) when delay would seriously jeopardize your health. Your physician must provide a letter supporting the urgency.

Does step therapy apply to Photrexa? Aetna typically requires documentation of failed conservative management (glasses, contact lenses) before approving corneal cross-linking, but formal step therapy protocols vary by plan.

What happens if my external review is denied? Michigan external review decisions are binding on insurance companies. If approved, Aetna must provide coverage. If denied, you may have limited options for further appeal through the courts.

Are there Michigan-specific resources for insurance appeals? Yes, contact Michigan DIFS at 877-999-6442 for free consumer assistance with insurance appeals and external reviews.

When to Get Help

Consider professional assistance from Counterforce Health if you're facing complex denials or need help navigating the appeals process. Their platform specializes in turning insurance denials into targeted, evidence-backed appeals by analyzing denial letters, plan policies, and clinical notes to draft point-by-point rebuttals aligned with each payer's specific requirements.

Contact Michigan DIFS at 877-999-6442 if you need help understanding your appeal rights or filing an external review request. DIFS provides free consumer assistance and can guide you through Michigan's specific appeal processes.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage varies by plan and individual circumstances. Always verify current requirements with your insurance company and consult your healthcare provider for medical decisions. For official Michigan insurance regulations and consumer assistance, contact the Michigan Department of Insurance and Financial Services at 877-999-6442.

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