By Counterforce Health Team in StrataGraft (allogeneic cultured keratinocytes & fibroblasts in murine collagen-dsat) —

How to Get StrataGraft Covered by Blue Cross Blue Shield in Ohio: Complete Prior Authorization and Appeals Guide

Answer Box: Getting StrataGraft Covered by BCBS Ohio

StrataGraft requires prior authorization from Blue Cross Blue Shield Ohio for adults with deep partial-thickness thermal burns when surgical intervention is clinically indicated. The fastest path to approval: (1) Ensure patient meets FDA criteria—adults with intact dermal elements, (2) Submit comprehensive PA request with burn specialist documentation, wound measurements, and clinical photos through BCBS provider portal, (3) If denied, file internal appeal within 180 days with detailed medical necessity letter. Ohio residents have external review rights through the Department of Insurance after exhausting internal appeals.

Table of Contents

  1. Plan Types & Network Requirements
  2. StrataGraft Formulary Status
  3. Prior Authorization Requirements
  4. Medical Necessity Criteria
  5. Specialty Pharmacy Network
  6. Cost-Share Considerations
  7. Submission Process
  8. Common Approval Patterns
  9. Appeals Process for Ohio
  10. Frequently Asked Questions

Plan Types & Network Requirements

Blue Cross Blue Shield Ohio operates multiple plan types, each with different requirements for StrataGraft coverage:

Commercial Plans (HMO/PPO/EPO)

  • Prior authorization mandatory for all plan types
  • PPO plans allow out-of-network burn centers with higher cost-sharing
  • HMO plans require referrals to in-network burn specialists

Medicare Advantage

  • Enhanced documentation requirements effective 2024
  • May require step therapy documentation starting January 2025
  • External review through Ohio Department of Insurance available

Medicaid Plans (CareSource Ohio)

StrataGraft Formulary Status

StrataGraft is not an open-access formulary item on BCBS Ohio plans. Key coverage details:

Coverage Aspect Details Source
HCPCS Code J7353 (facility billing) BCBS Medical Policy
Prior Auth Required Yes, mandatory Verified 2024
Step Therapy Not universally required Plan-specific
Age Restriction Adults (18+) only FDA Label
Diagnosis Limitation Deep partial-thickness thermal burns FDA-approved indication
Note: StrataGraft is billed as a medical procedure under facility benefits, not through pharmacy benefits.

Prior Authorization Requirements

BCBS Ohio requires comprehensive documentation for StrataGraft approval:

Required Documentation

  1. Patient eligibility confirmation
    • Age verification (18+ years)
    • Deep partial-thickness thermal burn diagnosis
    • Intact dermal elements present
  2. Clinical justification
    • Burn specialist consultation notes
    • Total body surface area (TBSA) calculation
    • Wound measurements in cm²
    • High-quality clinical photographs
  3. Treatment history
    • Prior wound care attempts
    • Response to conservative therapy
    • Contraindications to autografting (if applicable)
  4. Surgical planning
    • Planned intervention details
    • Site of care specification
    • Administration timeline

Medical Necessity Criteria

BCBS Ohio follows specific medical necessity criteria for burn treatment coverage:

StrataGraft is considered medically necessary when:

  • Patient has excised deep partial-thickness burn wounds
  • Surgical intervention (excision and grafting) is clinically indicated
  • Wound contains intact dermal elements
  • Standard wound care is insufficient for expected healing

Exclusion criteria:

  • Pediatric patients under 18 years
  • Burns on face, hands, feet, or joints
  • Active wound infection
  • Immunocompromised patients
  • Pregnancy
  • Known allergies to murine/bovine products

Specialty Pharmacy Network

Anthem Blue Cross Blue Shield Ohio maintains a designated specialty pharmacy network for specialty medications including StrataGraft.

Key requirements:

  • Burn centers must obtain StrataGraft through network-approved specialty pharmacies
  • Non-network facilities must coordinate with participating specialty pharmacies
  • Network requirements effective since January 1, 2022

Actionable steps:

  1. Verify burn center's pharmacy network status
  2. Coordinate prescription routing through approved partners
  3. Confirm prior authorization before ordering

Cost-Share Considerations

StrataGraft cost-sharing varies by plan type and benefit structure:

Typical cost-sharing patterns:

  • Deductible: May apply before coverage begins
  • Coinsurance: Usually 10-30% for in-network facilities
  • Copay: Fixed amount for some HMO plans
  • Out-of-network: Significantly higher cost-sharing
Educational note: These are general patterns. Individual cost-sharing depends on specific plan benefits. Contact BCBS Ohio member services for exact amounts.

Submission Process

Step-by-Step Prior Authorization Process

  1. Gather required documentation (Patient/Clinic)
    • Insurance verification and policy details
    • Complete medical records and burn assessment
    • Clinical photographs and wound measurements
    • Timeline: 1-2 business days
  2. Submit PA request (Clinic)
    • Use BCBS Ohio provider portal
    • Include all required documentation
    • Submit at least 5-7 business days before planned procedure
    • Timeline: Same day submission
  3. BCBS review process (Insurer)
    • Initial review within 14 calendar days
    • May request additional information
    • Expedited review available for urgent cases (72 hours)
  4. Receive determination (All parties)
    • Approval: Proceed with treatment planning
    • Denial: Review denial reason and prepare appeal
    • Timeline: Within review period specified

Common Approval Patterns

Successful StrataGraft approvals typically include:

Strong submission elements:

  • Detailed burn specialist evaluation
  • Clear documentation of burn depth and TBSA
  • High-quality wound photographs
  • Specific medical necessity justification
  • Complete prior treatment history

Red flags that lead to denial:

  • Incomplete wound assessment
  • Missing clinical photographs
  • Insufficient burn depth documentation
  • Off-label use requests
  • Inadequate specialist involvement
From our advocates: We've seen the strongest approvals include a comprehensive medical necessity letter that specifically addresses why StrataGraft is preferred over autografting, with detailed wound measurements and clear photos showing intact dermal elements. This documentation approach significantly improves approval odds.

Appeals Process for Ohio

If StrataGraft is initially denied, Ohio residents have robust appeal rights:

Internal Appeals

  • Deadline: 180 calendar days from denial notice
  • Timeline: 30 days for standard review, 72 hours for expedited
  • Process: Submit through BCBS Ohio member/provider portal
  • Required: All supporting medical documentation

External Review (IRO)

  • Eligibility: After exhausting internal appeals
  • Deadline: 120 days from final internal denial
  • Timeline: 30 days for standard, 72 hours for expedited
  • Cost: No charge to member
  • Contact: Ohio Department of Insurance at 800-686-1526

Appeals playbook:

  1. Request complete denial file from BCBS Ohio
  2. Gather additional supporting evidence
  3. Draft comprehensive rebuttal letter
  4. Submit within required timeframes
  5. Consider external review if internal appeals fail

When patients face complex coverage challenges, Counterforce Health helps turn insurance denials into targeted, evidence-backed appeals by analyzing denial letters and drafting point-by-point rebuttals aligned to each plan's specific requirements.

Frequently Asked Questions

How long does BCBS Ohio prior authorization take for StrataGraft? Standard review takes up to 14 calendar days. Expedited review (for urgent cases) is completed within 72 hours when clinical urgency is documented.

What if StrataGraft is considered non-formulary by my plan? StrataGraft requires case-by-case review regardless of formulary status. Focus on meeting medical necessity criteria and providing comprehensive clinical documentation.

Can I request an expedited appeal in Ohio? Yes, expedited appeals are available when treatment delay would seriously jeopardize health or recovery. Your treating physician must certify medical urgency.

Does step therapy apply if I've failed treatments outside Ohio? Prior treatment history from any location is typically accepted. Document all previous therapies, responses, and reasons for discontinuation.

What happens if my burn center isn't in the BCBS Ohio network? Out-of-network care is possible but results in higher cost-sharing. Consider requesting a network adequacy exception if no in-network burn specialists are available.

How do I verify current BCBS Ohio coverage policies? Check the Anthem medical policy database for the most current StrataGraft coverage criteria and requirements.

What documentation strengthens a StrataGraft appeal? Include detailed burn specialist notes, wound progression photos, failed conservative therapy documentation, and specific citations to FDA labeling and burn treatment guidelines.

Can Counterforce Health help with my StrataGraft appeal? Counterforce Health specializes in turning insurance denials into evidence-backed appeals by analyzing payer policies and crafting targeted rebuttals with appropriate clinical citations.

Coverage at a Glance

Requirement Details Where to Find Source
Prior Auth Required for all plans BCBS provider portal Medical Policy
Age Limit Adults 18+ only FDA labeling FDA Approval
Diagnosis Deep partial-thickness thermal burns Medical policy BCBS clinical criteria
HCPCS Code J7353 (facility billing) Billing guidelines Provider manual
Appeal Deadline 180 days from denial Member handbook Ohio DOI
External Review 120 days from final denial State regulations Ohio Insurance Code

When to Escalate

Contact the Ohio Department of Insurance at 800-686-1526 if:

  • BCBS Ohio fails to respond within required timeframes
  • Appeal rights are denied inappropriately
  • You need assistance with the external review process
  • Coverage disputes involve potential regulatory violations

Sources & Further Reading

Disclaimer: This information is educational and not medical advice. Coverage decisions depend on individual plan benefits and clinical circumstances. Always verify current policies with your insurer and consult healthcare providers for medical guidance. For additional support with complex appeals, consider consulting with coverage advocacy services that specialize in insurance denials and prior authorization challenges.

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