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

How to Get StrataGraft Covered by Humana in California: Prior Authorization Guide, Appeal Forms & Resources

Answer Box: Getting StrataGraft Covered by Humana in California

StrataGraft requires prior authorization from Humana for deep partial-thickness burns in adults 18+. Submit through your provider via the medical benefit pathway (not pharmacy) using HCPCS code J7353. If denied, file an internal appeal within 65 days, then request California's Independent Medical Review (IMR) through DMHC at no cost. Start today: Have your burn surgeon verify PA requirements and gather wound documentation including measurements and photos.

Fastest approval path: Medical necessity documentation → Provider portal submission → Standard review (15 days) or expedited (24 hours for urgent cases).

Table of Contents

Coverage Requirements at a Glance

Requirement Details Where to Find Source
Prior Authorization Required for all Humana Medicare Advantage plans Humana PA Search Tool Provider Portal
Age Limit 18 years or older only FDA labeling requirements FDA Package Insert
Diagnosis Deep partial-thickness thermal burns with intact dermal elements Medical necessity criteria Humana Coverage Policies
Billing Pathway Medical benefit (Part B) only - HCPCS J7353 Never pharmacy benefit Provider Guidelines
Step Therapy May require trial of alternative treatments (2025) Part B step therapy list 2025 Preferred Drug List
Appeals Deadline 65 days from denial for internal appeal Medicare guidelines Humana Member Rights

Step 1: Verify Your Plan and Find the Right Forms

Check Your Humana Plan Type

First, confirm whether you have a Humana Medicare Advantage plan or commercial insurance, as this determines which forms and processes apply.

For Medicare Advantage members:

  • Log into your Humana member portal to verify coverage details
  • Look for "Medicare Advantage" or "HMO-POS" on your insurance card
  • Note your plan year, as policies update annually

For commercial plan members:

  • Contact Humana customer service at the number on your card
  • Ask specifically about skin substitute coverage policies
  • Request your current Summary of Benefits and Coverage (SBC)
Tip: California residents with Humana HMO plans fall under DMHC regulation, which provides stronger appeal rights than other states.

Locate Current Policy Documents

StrataGraft coverage falls under Humana's skin and tissue substitute policies. Access the most current version through their medical coverage policy database by searching for "skin substitutes" or policy codes beginning with "S."

Step 2: Prior Authorization Forms and Submission

Required Documentation Checklist

Your burn surgeon or wound care specialist will need to submit:

Clinical Documentation:

  • Burn assessment with depth determination (deep partial-thickness confirmed)
  • Wound measurements in square centimeters (required for J7353 billing)
  • High-quality photographs showing burn characteristics
  • Documentation that autografting is clinically indicated
  • Prior treatment attempts and outcomes
  • Surgical plan and timeline

Administrative Requirements:

  • Patient demographics and Humana member ID
  • ICD-10 diagnosis codes (T21-T31 series for thermal burns)
  • Provider NPI and facility information
  • Attestation of medical necessity
Note: StrataGraft is billed per square centimeter, so precise wound measurements are critical for both approval and reimbursement.

Medical Necessity Letter Template

Your provider should include these key elements in the PA request:

  1. Patient presentation: Age, burn mechanism, total body surface area affected
  2. Clinical rationale: Why StrataGraft is appropriate over alternatives
  3. Treatment goals: Expected outcomes and healing timeline
  4. Monitoring plan: Follow-up schedule and success metrics

Step 3: Submission Portals and Upload Requirements

Primary Submission Methods (Ranked by Speed)

1. Availity Provider Portal (Fastest)

  • Access through provider.humana.com login
  • Use "Prior Authorization" section under Coverage & Claims
  • Upload all documentation as PDFs
  • Real-time status tracking available
  • Timeline: Standard decisions within 15 business days, expedited within 24 hours

2. CoverMyMeds Integration

  • For providers already using CoverMyMeds
  • Select Humana as payer and enter patient information
  • Follow prompts for skin substitute PA
  • Automatic routing to appropriate review team

Upload Requirements and File Formats

  • File types accepted: PDF, JPEG, PNG
  • Maximum file size: 10MB per document
  • Required uploads: Clinical notes, wound photos, prior authorization form, supporting literature if applicable
  • Naming convention: Use patient last name and document type (e.g., "Smith_WoundPhotos.pdf")

Step 4: Alternative Submission Methods

Fax Submission

Primary fax number: 877-486-2621 Cover sheet requirements:

  • Patient name and Humana member ID
  • Provider name and NPI
  • "URGENT - StrataGraft Prior Authorization" in subject line
  • Page count and document list
Important: Always call to confirm fax receipt within 24 hours at 800-555-CLIN (2546).

Phone Submission for Urgent Cases

For life-threatening burns requiring expedited review:

  • Provider line: 800-555-CLIN (2546)
  • Hours: Monday-Friday, 8 AM - 8 PM local time
  • Information needed: Patient demographics, clinical summary, urgency rationale
  • Follow-up: Written documentation must be submitted within 48 hours

Step 5: Track Your Request and Get Support

Monitoring Your PA Status

  • Online: Log into Availity portal for real-time updates
  • Phone: Call provider services at 800-555-CLIN (2546)
  • Automated system: Use Humana's automated PA status line with your reference number

Getting Help During the Process

For providers:

  • Clinical consultations available during PA review
  • Peer-to-peer review requests if initial denial occurs
  • Case management support for complex burns

For patients and families:

  • Member services at the number on your insurance card
  • Request case manager assignment for coordinated care
  • Counterforce Health provides specialized support for insurance denials and appeals, helping patients and providers build stronger cases with evidence-based documentation

Appeals Process: Internal and California IMR

Internal Appeals with Humana

If your StrataGraft request is denied, you have 65 days to file an internal appeal.

How to file:

  1. Use the appeal form included with your denial letter
  2. Submit via member portal or mail to address on denial notice
  3. Include additional clinical documentation if available
  4. Request expedited review if medically urgent

Timeline: Humana has 30 days for standard appeals, 72 hours for expedited

California Independent Medical Review (IMR)

California residents have powerful external appeal rights through the Department of Managed Health Care.

When to use IMR:

  • Humana upholds the denial after internal appeal
  • Denial is based on "not medically necessary" or "experimental"
  • You've exhausted Humana's grievance process (or waited 30 days)

How to file:

  1. Visit dmhc.ca.gov/FileaComplaint
  2. Complete the IMR application online
  3. Upload denial letters and medical records
  4. No fee required - California covers all costs

IMR Timeline:

  • Standard review: 45 days maximum
  • Expedited review: 7 days (often within 72 hours)
  • Decision is binding on Humana
California Advantage: IMR success rates are high for medically necessary treatments. In 2023, DMHC overturned 55.3% of medical necessity denials across all plans.

Common Denial Reasons and How to Fix Them

Denial Reason Solution Documentation Needed
"Not FDA approved indication" Confirm deep partial-thickness thermal burns Burn assessment, wound photos, pathology if available
"Alternative treatments not tried" Document failed conventional therapy Prior treatment records, clinical notes showing inadequate healing
"Insufficient wound documentation" Provide detailed measurements and photos Square centimeter measurements, standardized wound photos
"Billed incorrectly" Ensure medical benefit billing Resubmit with HCPCS J7353, never through pharmacy
"Step therapy required" Request exception or document failures Medical necessity letter citing burn severity, time-sensitive nature

Scripts for Common Situations

Patient calling Humana: "I'm calling about my StrataGraft prior authorization request for deep partial-thickness burns. My reference number is [X]. Can you tell me the current status and what additional information might be needed?"

Provider requesting peer-to-peer: "I'm requesting a peer-to-peer review for my StrataGraft PA denial. The patient has extensive deep partial-thickness burns where autografting is indicated, and StrataGraft could reduce donor site morbidity. When can we schedule the clinical discussion?"

California Consumer Protection Resources

Getting Free Help with Appeals

DMHC Help Center

  • Phone: 1-888-466-2219
  • Website: healthhelp.ca.gov
  • Services: IMR assistance, complaint filing, plan compliance issues

Health Consumer Alliance

  • Nonprofit organization providing free insurance advocacy
  • Specializes in complex medical appeals
  • Can assist with IMR preparation and documentation

Legal Aid Organizations

  • Available for low-income patients facing coverage denials
  • Can provide representation in complex appeals
  • Search by county at lawhelpca.org

When to Escalate to Regulators

Contact DMHC if Humana:

  • Fails to respond to PA requests within required timeframes
  • Doesn't provide proper appeal rights information
  • Creates barriers to accessing covered benefits
  • Violates California insurance regulations

When to Check for Updates

Quarterly Review Schedule

January, April, July, October:

  • Check Humana's updated coverage policies
  • Review any changes to step therapy requirements
  • Verify current PA forms and submission processes
  • Confirm portal access and contact information

Policy Change Notifications

  • Subscribe to Humana provider updates if you're a healthcare professional
  • Monitor Counterforce Health's coverage updates for StrataGraft policy changes
  • Check DMHC website for new consumer protection regulations

Annual Open Enrollment Considerations

  • Review plan formularies and coverage policies
  • Compare StrataGraft coverage across available Humana plans
  • Consider supplemental coverage options if needed

Frequently Asked Questions

How long does Humana prior authorization take for StrataGraft in California? Standard review takes up to 15 business days, while expedited review for urgent cases is completed within 24 hours of receiving complete documentation.

What if StrataGraft isn't on Humana's formulary? StrataGraft is covered under the medical benefit, not pharmacy formulary. It's billed using HCPCS code J7353 through hospital or outpatient facility claims.

Can I request an expedited appeal in California? Yes, both Humana internal appeals and DMHC IMR offer expedited review for urgent medical situations. Document the clinical urgency in your request.

Does step therapy apply if I've tried treatments outside California? Yes, prior treatment history from any location counts toward step therapy requirements. Provide documentation from all previous providers.

What's the success rate for StrataGraft appeals in California? While specific StrataGraft data isn't published, California's IMR process overturns approximately 55% of medical necessity denials, with higher success rates for well-documented cases.

Can my family help with the appeal process? Yes, you can designate a family member or advocate to assist with your appeal. Provide written authorization to Humana and DMHC.

Sources & Further Reading

Disclaimer: This guide provides educational information about insurance coverage processes and should not be considered medical or legal advice. Coverage decisions depend on individual circumstances, plan details, and medical necessity. Always consult with your healthcare provider about treatment options and contact Humana directly for plan-specific information. For assistance with complex appeals, consider contacting qualified patient advocates or legal professionals specializing in health insurance matters.

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