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

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

Answer Box: Getting Photrexa Covered by Aetna CVS Health in Ohio

Aetna CVS Health covers epithelium-off corneal cross-linking with Photrexa for progressive keratoconus and ectasia. The fastest path to approval: 1) Verify your plan covers CPT code 0402T, 2) Submit prior authorization with documented keratoconus progression (serial topography, Kmax increases), and 3) Use an in-network ophthalmologist familiar with CXL procedures. Start today by calling Aetna member services at 1-800-872-3862 to confirm your specific plan's requirements and locate in-network providers.

Table of Contents

What This Guide Covers

This comprehensive guide helps patients and clinicians navigate Aetna CVS Health's prior authorization process for Photrexa (riboflavin ophthalmic solution) used in corneal collagen cross-linking (CXL) procedures in Ohio. Whether you're dealing with progressive keratoconus or corneal ectasia, this step-by-step approach will help you secure coverage for this FDA-approved treatment.

Who This Helps:

  • Patients diagnosed with progressive keratoconus or ectasia
  • Ophthalmologists and their staff managing prior authorizations
  • Caregivers advocating for family members needing CXL treatment
Expected Outcome: With proper documentation of keratoconus progression, Aetna CVS Health typically approves epithelium-off CXL procedures. More than 95% of commercially insured patients now have access to FDA-approved corneal cross-linking.

Before You Start: Plan Verification

Step 1: Confirm Your Plan Type

Call Aetna member services at 1-800-872-3862 to verify:

  • Whether your plan is fully insured (subject to Ohio regulations) or self-funded (ERISA-governed)
  • Your specific medical policy number
  • Whether corneal procedures require prior authorization

Step 2: Verify Network Status

Ensure your ophthalmologist is in-network with Aetna CVS Health. Out-of-network providers may result in higher costs or coverage denials, even for medically necessary procedures.

Step 3: Check Medical vs. Pharmacy Benefit

Photrexa and CXL procedures are typically covered under the medical benefit (not pharmacy). The procedure uses:

  • CPT Code 0402T (Collagen cross-linking of cornea)
  • J-Code J2787 (Riboflavin medication, 2 units per procedure)

Coverage at a Glance

Requirement What It Means Where to Find It Status
Prior Authorization Pre-approval needed for CXL Aetna Precertification Lists Verify with plan
FDA-Approved System Only epithelium-off CXL covered Aetna Medical Policy Required
Progressive Disease Documented worsening keratoconus Serial topography/Kmax Required
In-Network Provider Ophthalmologist contracted with Aetna Provider directory Required
Minimum Thickness Usually ≥400 microns corneal thickness Pachymetry results Varies by protocol

Gather Required Documentation

Essential Clinical Records

1. Diagnostic Documentation:

  • Confirmed keratoconus or ectasia diagnosis with ICD-10 code
  • Serial corneal topography images showing progression
  • Kmax (maximum keratometry) values demonstrating increase over time
  • Pachymetry measurements confirming adequate corneal thickness

2. Progression Evidence: Documentation must show objective worsening over time, typically including:

  • Increasing corneal steepening (Kmax values)
  • Changes in corneal shape on topography
  • Corneal thinning patterns
  • Visual acuity changes (if applicable)
Tip: The most common reason for CXL denials is insufficient documentation of disease progression. Ensure you have at least two sets of measurements taken months apart.

3. Prior Treatment History:

  • Contact lens fitting attempts and outcomes
  • Any previous surgical interventions
  • Response to conservative management

Administrative Requirements

  • Current insurance card and policy information
  • Referral from primary care physician (if required by plan)
  • Completed prior authorization forms
  • Provider's DEA and NPI numbers

Submit Your Prior Authorization Request

Step 1: Access Aetna's Prior Authorization System

Your ophthalmologist can submit requests through:

  • Aetna Provider Portal (preferred method)
  • Fax: Check current fax number through provider portal
  • Phone: 1-855-240-0536 (verify current number)

Step 2: Complete Required Forms

While Photrexa may not appear on standard prior authorization lists, specialty ophthalmic procedures often require review. Your provider should:

  1. Complete Aetna's medical prior authorization form
  2. Include detailed clinical notes supporting medical necessity
  3. Attach all required documentation listed above
  4. Specify the exact procedure (epithelium-off CXL with iLink system)

Step 3: Submit Clean Request Packet

Checklist for Submission:

  • Completed PA form with all required fields
  • Serial corneal topography images
  • Kmax progression data
  • Pachymetry results
  • Clinical notes with diagnosis and treatment rationale
  • Prior treatment history
  • Provider attestation of medical necessity

Clinician Corner: Medical Necessity Letter

Key Elements to Include:

  • Patient's age and specific keratoconus/ectasia diagnosis
  • Objective evidence of disease progression with dates
  • Prior conservative treatments attempted and outcomes
  • Clinical rationale for CXL at this time
  • Reference to FDA approval of epithelium-off CXL
  • Expected treatment outcomes and monitoring plan

Supporting Guidelines:

  • FDA labeling for iLink system
  • Aetna's medical policy supporting epithelium-off CXL for keratoconus
  • American Academy of Ophthalmology practice patterns

Follow-Up and Timeline Expectations

Standard Processing Times

Aetna CVS Health Timelines:

  • Standard Review: 30-45 days from complete submission
  • Expedited Review: 72 hours for urgent medical situations
  • Additional Information Requests: May extend timeline by 14 days

When and How to Follow Up

Week 1: Confirm receipt of your submission

  • Call provider services to verify PA request was received
  • Document reference number for tracking
  • Ensure all required documents were included

Week 2-3: Check status if no response

  • Use provider portal to check status
  • Call if status hasn't updated
  • Be prepared with PA reference number

Sample Follow-Up Script

"I'm calling to check the status of a prior authorization request for corneal collagen cross-linking, reference number [X]. The patient has progressive keratoconus and we submitted complete documentation on [date]. Can you provide an update on the review timeline?"

If You Need More Information

Medical Necessity Questions

If Aetna requests additional clinical information:

Common Requests:

  • More recent topography images
  • Detailed progression timeline
  • Specialist consultation notes
  • Alternative treatment considerations

How to Respond:

  • Submit requested information promptly (usually within 14 days)
  • Include cover letter explaining how new information supports medical necessity
  • Reference Aetna's own medical policy supporting CXL for progressive keratoconus

Peer-to-Peer Review Requests

If Aetna requests a peer-to-peer discussion:

  • Schedule within requested timeframe (typically 72 hours)
  • Prepare clinical summary and key progression data
  • Have patient chart and imaging available during call
  • Emphasize FDA approval and established safety profile

If Your Request is Denied

Common Denial Reasons & Solutions

Denial Reason How to Address Required Documentation
"Not medically necessary" Submit progression evidence Serial topography, Kmax data
"Experimental/investigational" Cite FDA approval FDA labeling, Aetna policy
"Epithelium-on procedure" Clarify epithelium-off protocol Procedure details, iLink system
"Insufficient progression" Provide additional imaging More topography dates, measurements

First-Level Internal Appeal

Timeline: Must be filed within 180 days of denial Process:

  1. Request written denial with specific reasons
  2. Gather additional supporting documentation
  3. Submit formal appeal letter addressing each denial reason
  4. Include peer-reviewed literature supporting CXL efficacy
From Our Advocates: We've seen many initial denials reversed when providers submit comprehensive progression documentation spanning 6-12 months. The key is demonstrating objective worsening through multiple measurement points, not just a single concerning reading.

Appeals Process in Ohio

Ohio-Specific Rights

Ohio residents have strong appeal protections:

  • Two levels of internal appeals with Aetna
  • External review through Ohio Department of Insurance
  • 180-day deadline to request external review after final internal denial

Internal Appeals with Aetna CVS Health

Level 1 Appeal:

  • Timeline: 180 days from denial to file
  • Decision: 30 days for standard, 72 hours for expedited
  • How to File: Written request through member portal or mail

Level 2 Appeal (if needed):

  • Timeline: 60 days from Level 1 denial
  • Decision: 30 days for standard review
  • Requirements: Must include new information or evidence

External Review Through Ohio Department of Insurance

If Aetna upholds the denial after internal appeals:

Contact Information:

  • Ohio Department of Insurance: insurance.ohio.gov
  • Consumer Hotline: 1-800-686-1526
  • External Review Form: Available on ODI website

Process:

  1. Request external review within 180 days of final denial
  2. Independent Review Organization (IRO) assigned
  3. Medical experts review case within 30 days
  4. Decision is binding on Aetna

When to Contact Ohio Regulators

Contact the Ohio Department of Insurance if:

  • Aetna refuses to process your internal appeal
  • Appeal deadlines are not met by the insurer
  • You need help understanding your appeal rights
  • Aetna claims external review is not available

Renewal and Re-Authorization

When to Reauthorize

CXL is typically a one-time procedure per eye, but reauthorization may be needed if:

  • Treatment is delayed beyond initial approval period
  • Bilateral treatment requires separate authorizations
  • Follow-up procedures are recommended

What to Include for Renewal

  • Updated clinical status
  • Results from previous treatment (if applicable)
  • Current imaging and measurements
  • Continued medical necessity justification

Quick Reference Checklist

Before Starting:

  • Verify Aetna plan covers CXL (CPT 0402T)
  • Confirm provider is in-network
  • Gather 6+ months of progression data

For Submission:

  • Complete prior authorization form
  • Serial topography images
  • Kmax progression documentation
  • Pachymetry confirming adequate thickness
  • Clinical notes with medical necessity

After Submission:

  • Confirm receipt within 1 week
  • Follow up if no response in 2-3 weeks
  • Respond promptly to information requests
  • File appeal within 180 days if denied

FAQ

How long does Aetna CVS Health prior authorization take in Ohio? Standard reviews take 30-45 days from complete submission. Expedited reviews for urgent cases are completed within 72 hours.

What if Photrexa is considered non-formulary? Photrexa is typically covered under the medical benefit, not pharmacy formulary. The procedure itself (CPT 0402T) and riboflavin medication (J2787) are billed as medical services.

Can I request an expedited appeal in Ohio? Yes, if delaying treatment would seriously jeopardize your health or ability to regain maximum function. Contact Aetna member services to request expedited review.

Does step therapy apply to corneal cross-linking? Step therapy typically doesn't apply to CXL since it's a specialized procedure for progressive keratoconus. However, Aetna may require documentation of conservative management attempts.

What if my ophthalmologist is out-of-network? Out-of-network providers may result in higher costs or coverage denials. Consider seeking in-network care or requesting a network adequacy exception if no in-network CXL providers are available in your area.

How much does CXL cost if insurance doesn't cover it? The total procedure (including facility, physician, and medication costs) typically ranges from $2,500-$4,000 per eye. Some providers offer payment plans or may work with foundations for financial assistance.

Can I appeal to Ohio regulators if Aetna denies my claim? Yes, Ohio residents can request external review through the Ohio Department of Insurance within 180 days of final internal denial. The decision is binding on Aetna.

What counts as sufficient progression documentation? Objective evidence of worsening keratoconus over time, including increasing Kmax values, changes in corneal topography, and corneal thinning patterns. Serial measurements taken months apart provide the strongest evidence.

About Counterforce Health

Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into successful appeals. Our platform analyzes denial letters, identifies the specific denial basis, and creates targeted, evidence-backed rebuttals aligned to each payer's own coverage policies. For complex treatments like Photrexa, we help ensure that medical necessity letters include the right clinical evidence, FDA citations, and procedural documentation that payers expect to see.

For additional support with your Aetna appeal, Counterforce Health provides tools and templates that can help streamline the process and improve approval rates.

Sources & Further Reading

Disclaimer: This guide is for informational 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 personalized guidance. For additional help with insurance appeals in Ohio, contact the Ohio Department of Insurance at 1-800-686-1526.

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