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

How to Get Photrexa (Riboflavin) Covered by Humana in New Jersey: Complete Prior Authorization and Appeals Guide

Answer Box: Getting Photrexa Covered by Humana in New Jersey

Humana Medicare Advantage requires prior authorization for Photrexa (riboflavin ophthalmic solution) used in corneal cross-linking for progressive keratoconus. Approval depends on documented progression (Kmax increase ≥1.0 diopter over 6-12 months) and use of FDA-approved epithelium-off protocols at certified facilities.

First steps today:

  1. Confirm your ophthalmologist is Humana in-network and iLink® certified
  2. Gather serial corneal topography showing progression
  3. Submit prior authorization via Humana provider portal using CPT code 0402T

If denied, you have 65 days to appeal through Humana's internal process, then New Jersey's external review system if needed.

Table of Contents

Understanding Photrexa Coverage Requirements

Photrexa (riboflavin ophthalmic solution) is used with the iLink® system for FDA-approved epithelium-off corneal collagen cross-linking in progressive keratoconus. The procedure typically costs $2,500–$4,000 per eye, but coverage is increasing as evidence supports its effectiveness in halting keratoconus progression.

Humana Medicare Advantage covers conventional epithelium-off corneal cross-linking when specific medical necessity criteria are met. The key requirement is documented progression of keratoconus within the preceding 12 months, typically demonstrated through serial corneal topography measurements.

Note: Only the FDA-approved iLink system using Photrexa solutions and the KXL® device qualifies for coverage. Epithelium-on procedures and non-FDA approved systems are generally considered experimental and not covered.

Step-by-Step: Fastest Path to Approval

1. Confirm Provider Network Status (Patient/Clinic)

Timeline: Same day
Action: Verify your ophthalmologist participates in Humana Medicare Advantage and is certified for FDA-approved iLink procedures
Submit via: Humana provider directory or call member services

2. Document Keratoconus Progression (Clinic)

Timeline: 1-3 business days to gather records
Action: Collect serial corneal topography showing Kmax increase ≥1.0 diopter over 6-12 months, pachymetry measurements, and clinical notes
Required: At least two measurements taken 6+ months apart

3. Submit Prior Authorization (Clinic)

Timeline: 1-2 business days to prepare and submit
Action: Complete prior authorization request using CPT code 0402T
Submit via: Humana provider portal or fax (verify current number)

4. Standard Review Process (Humana)

Timeline: Up to 15 business days (standard), 72 hours (expedited)
Action: Humana reviews clinical documentation against coverage criteria
Expedited: Available if delay would harm patient's health

5. Receive Determination (Patient/Clinic)

Timeline: Within review timeframe
Action: Review approval letter or denial notice carefully
Next step: If denied, proceed to appeals process within 65 days

Coverage at a Glance

Requirement What It Means Where to Find It Source
Prior Authorization Required before procedure Humana provider portal Humana PA requirements
Progression Documentation Kmax increase ≥1.0D in 6-12 months Serial corneal topography Humana keratoconus policy
FDA-Approved System iLink® with Photrexa solutions only Certified facility required Glaukos iLink locator
CPT Code 0402T for corneal cross-linking Medical coding ASCRS billing guidelines
Appeal Deadline 65 days from denial notice Denial letter Humana appeals process

Common Denial Reasons & How to Fix Them

Denial Reason How to Overturn
Insufficient progression documentation Submit complete serial topography with clear Kmax increases and dates. Include pachymetry and visual acuity changes if available.
Non-FDA approved system Confirm procedure uses iLink® system with Photrexa solutions. Provide facility certification documentation.
Out-of-network provider Transfer care to in-network, certified ophthalmologist or request single-case agreement for specialty care.
Missing clinical justification Submit comprehensive medical necessity letter addressing diagnosis, progression, failed conservative treatments, and treatment goals.
Coding issues Verify CPT code 0402T is used correctly. Include appropriate ICD-10 codes (H18.621-H18.623 for keratoconus).

Appeals Playbook for New Jersey

Internal Appeals (Humana Process)

Level 1: Redetermination

  • Deadline: 65 days from denial notice
  • Timeline: 30 days for decision (72 hours if expedited)
  • How to file: Online via member portal, mail, or fax
  • Required: Appeal form or written request with supporting documentation

Level 2: Reconsideration

  • Deadline: 65 days from Level 1 denial
  • Timeline: 30 days for decision
  • Review: Independent contractor reviews case
  • Enhancement: Request peer-to-peer review with medical director

External Review (New Jersey IHCAP)

If Humana upholds the denial after internal appeals, New Jersey residents can access the Independent Health Care Appeals Program (IHCAP) through Maximus Federal Services.

Eligibility:

  • Completed Humana's internal appeal process
  • Denial based on medical necessity or coverage determination
  • Submit within 180 days of final internal denial

Process:

  • Submit appeal directly to Maximus (contact info provided by NJ DOBI)
  • Preliminary review within 5 business days
  • Full physician panel review within 45 days
  • Cost: Free to patient (insurer pays all fees)

Contact: NJ IHCAP Hotline: 1-888-393-1062

From our advocates: We've seen cases where comprehensive progression documentation initially seemed "borderline" but was successful on appeal when paired with a detailed medical necessity letter explaining the patient's specific clinical picture and risk of progression without treatment. The key is connecting objective measurements to functional impact and treatment urgency.

Medical Necessity Letter Requirements

Your ophthalmologist should include these elements in the medical necessity letter:

Clinical Justification Checklist

  • Diagnosis: Progressive keratoconus with ICD-10 code (H18.621-H18.623)
  • Progression evidence: Specific Kmax values and dates showing ≥1.0D increase
  • Conservative treatment failures: Contact lens intolerance, inadequate vision correction
  • Treatment rationale: Why cross-linking is appropriate now vs. observation
  • Contraindications to alternatives: Why other treatments aren't suitable
  • Expected outcomes: Stabilization goals and monitoring plan

Supporting Documentation

  • Serial corneal topography reports (minimum 2 time points)
  • Pachymetry measurements showing corneal thinning if applicable
  • Visual acuity records and refraction changes
  • Previous treatment attempts and outcomes
  • Peer-reviewed literature supporting treatment timing

Counterforce Health specializes in turning insurance denials into successful appeals by analyzing denial letters, plan policies, and clinical notes to create targeted, evidence-backed rebuttals. Their platform helps identify the specific denial basis and drafts point-by-point responses aligned to each plan's coverage criteria.

When Appeals Fail: Next Steps

If both internal and external appeals are unsuccessful:

Alternative Coverage Options

  • Formulary exception: Request coverage for non-formulary alternatives if applicable
  • Single-case agreement: For out-of-network specialty providers
  • Medical policy review: Challenge outdated coverage policies through plan's P&T committee

Financial Assistance

  • Glaukos Patient Services (GPS): Provides reimbursement support and patient assistance programs
  • Foundation grants: Organizations like the National Keratoconus Foundation may offer financial aid
  • Payment plans: Many ophthalmology practices offer structured payment options

Regulatory Complaints

  • New Jersey Department of Banking and Insurance: File complaint for coverage violations
  • Consumer Hotline: 1-800-446-7467 for guidance on insurance issues

Costs and Financial Assistance

The total cost for Photrexa treatment typically ranges from $2,500–$4,000 per eye, including the riboflavin solution, UV light procedure, and facility fees. With Humana coverage, your out-of-pocket costs depend on your specific plan's copays, deductibles, and coinsurance.

Financial Support Options:

  • Contact Glaukos Patient Services for insurance verification and patient assistance programs
  • Check eligibility for manufacturer copay assistance programs
  • Explore flexible spending account (FSA) or health savings account (HSA) options for tax-advantaged payment

FAQ

How long does Humana prior authorization take in New Jersey?
Standard review takes up to 15 business days. Expedited review (when delay could harm health) is completed within 72 hours. As of January 2026, Humana aims to process 95% of complete requests within one business day.

What if my ophthalmologist isn't Humana in-network?
You can request a single-case agreement if no in-network providers offer FDA-approved cross-linking in your area. This requires demonstrating medical necessity and lack of network adequacy.

Can I appeal if I already had the procedure?
Yes, you can appeal for reimbursement of services already provided. The same 65-day deadline applies from the date of denial, and New Jersey allows appeals for post-service coverage determinations.

Does step therapy apply to Photrexa?
Cross-linking isn't typically subject to step therapy since it's a procedure rather than a medication. However, insurers may require documentation of failed conservative treatments like specialty contact lenses.

What's the difference between epithelium-off and epithelium-on procedures?
Only epithelium-off cross-linking using the FDA-approved iLink system is covered by insurance. Epithelium-on procedures are considered experimental and aren't covered by Humana or other major insurers.

How do I request an expedited appeal?
Contact Humana immediately if waiting for the standard appeal timeline could harm your health or vision. Provide clinical documentation supporting the urgency of treatment.

What happens if New Jersey's external review overturns Humana's denial?
If the Independent Health Care Appeals Program rules in your favor, Humana must comply and cover the service. This decision is binding and enforceable under New Jersey law.

Can my doctor file the appeal for me?
Yes, your ophthalmologist can file appeals on your behalf with your written consent. Many practices have billing specialists experienced in handling prior authorizations and appeals.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage policies vary by plan and individual circumstances. Always consult with your healthcare provider and insurance plan for specific coverage determinations. Counterforce Health provides specialized support for navigating insurance appeals and prior authorization requirements, helping patients and providers turn denials into successful approvals through evidence-based advocacy.

Powered by Counterforce Health—AI that turns drug denials into evidence-based appeals patients and clinicians can submit today.