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

How to Get StrataGraft Covered by Humana in Illinois: Coding, Appeals & Prior Authorization Guide

Answer Box: StrataGraft requires prior authorization from Humana Medicare Advantage in Illinois, billed as medical benefit using HCPCS J7353. Submit PA request with ICD-10 burn codes (T21-T31), wound measurements, and clinical documentation. If denied, file internal appeal within 60 days, then Illinois external review within 4 months. Start today: gather medical records and contact your provider to initiate the PA process through Humana's provider portal.

Table of Contents

Medical vs. Pharmacy Benefit Pathways

StrataGraft (allogeneic cultured keratinocytes & fibroblasts in murine collagen-dsat) is always billed through the medical benefit, not the pharmacy benefit. This tissue-engineered skin substitute is applied during surgical procedures in hospital or outpatient settings.

Key Differences:

Aspect Medical Benefit (StrataGraft) Pharmacy Benefit
Billing Channel CMS-1500 or UB-04 forms NCPDP pharmacy claims
HCPCS Code J7353 (per square centimeter) N/A
Place of Service Hospital, ASC, physician office Retail/specialty pharmacy
Prior Authorization Required through medical PA Not applicable

StrataGraft is manufactured by Mallinckrodt and indicated for deep partial-thickness thermal burns in adults when autografting is clinically indicated. The product promotes regeneration and may reduce the need for autograft at the treated site.

ICD-10 Coding for Deep Partial-Thickness Burns

Accurate ICD-10 coding is crucial for Humana prior authorization approval. Deep partial-thickness thermal burns require specific codes from the T21-T31 range.

Primary ICD-10 Codes:

  • T21.21XA: Deep partial-thickness burn of trunk, initial encounter
  • T22.21XA: Deep partial-thickness burn of shoulder/upper limb
  • T23.21XA: Deep partial-thickness burn of wrist/hand
  • T24.21XA: Deep partial-thickness burn of hip/lower limb
  • T25.21XA: Deep partial-thickness burn of ankle/foot

Additional Required Codes:

  • T31.XX: Burn involving X% of body surface (specify total body surface area)
  • External cause codes (Y92.XX for place of occurrence, if applicable)

Documentation Requirements:

  • Burn depth confirmation (deep partial-thickness)
  • Anatomical location and size measurements
  • Percentage of total body surface area affected
  • Photographic evidence or wound measurements
  • Failed response to standard wound care (if applicable)
Tip: Use the most specific ICD-10 code available. The sixth character "2" indicates deep partial-thickness, and the seventh character "A" denotes initial encounter.

Product Coding: HCPCS, Units, and Modifiers

HCPCS Code: J7353 - "StrataGraft, per square centimeter"

Unit Calculation:

  • Each StrataGraft construct covers approximately 100 cm²
  • Bill by actual square centimeters applied, not by construct
  • Round up to the next whole square centimeter if needed
  • Document exact wound measurements in medical records

Common Modifiers:

  • -JW: Drug amount discarded/not administered (for wastage)
  • -59: Distinct procedural service (when multiple procedures performed)
  • -RT/-LT: Right/left side (when applicable for bilateral wounds)

Billing Example:

  • Wound size: 180 cm²
  • Units billed: 180 (under J7353)
  • If using 2 constructs with 20 cm² wastage, add modifier -JW for discarded amount

Clean Prior Authorization Request

A complete prior authorization request should include:

Required Documentation:

  1. Clinical indication with specific ICD-10 codes
  2. Wound measurements and photographs (if available)
  3. Treatment history including failed standard therapies
  4. Surgical plan with estimated StrataGraft quantity needed
  5. Medical necessity justification referencing clinical guidelines

Sample PA Request Structure:

Patient: [Name, DOB, Humana ID]
Diagnosis: Deep partial-thickness thermal burn, trunk (T21.21XA)
Wound size: 150 cm² (15cm x 10cm area)
Prior treatments: Standard wound care x 4 weeks without adequate healing
Requested: StrataGraft 150 sq cm (J7353 x 150 units)
Clinical rationale: [Evidence-based justification]
Clinician Corner: Include peer-reviewed evidence supporting StrataGraft use, FDA labeling information, and burn care guidelines. Document why autografting alone is insufficient or contraindicated.

Common Billing Pitfalls

Top Denial Reasons and Solutions:

Denial Reason Solution Documentation Needed
Unit calculation errors Match billed units to documented wound area Precise measurements, photos
Missing modifiers Use -JW for wastage, -59 for distinct procedures Detailed surgical notes
Facility vs. physician duplicate billing Clarify who bills for product vs. application Clear billing agreements
Insufficient medical necessity Strengthen clinical justification Prior therapy failures, guidelines
Wrong benefit category Ensure medical benefit billing, not pharmacy Correct claim forms (CMS-1500/UB-04)

Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals. The platform helps identify denial reasons and drafts point-by-point rebuttals aligned to each plan's specific requirements, including Humana's policies for products like StrataGraft.

Verification with Humana Resources

Before submitting your request, verify current requirements:

Humana Provider Resources:

  • Provider portal for PA forms and status
  • Prior authorization search tool for current requirements
  • Coverage policies for skin substitutes and biologics
  • Step therapy requirements (effective 2025)

Key Verification Steps:

  1. Confirm StrataGraft is on current PA list
  2. Check for step therapy requirements
  3. Verify required documentation
  4. Confirm submission method (portal vs. fax)
Note: Humana Medicare Advantage plans may require step therapy starting January 2025, meaning patients must try less expensive alternatives first unless contraindicated.

Appeals Process for Illinois Patients

If Humana denies your StrataGraft request, Illinois provides strong appeal rights:

Internal Appeal Process:

  • Timeline: 60 days from denial notice to file
  • Decision: 15 business days for pre-service requests
  • Expedited: 24 hours for urgent cases
  • Submit to: Humana appeals department (check EOB for specific address)

Illinois External Review:

  • Eligibility: After exhausting internal appeals
  • Timeline: 4 months from final denial to request external review
  • Process: Independent physician reviewer makes binding decision
  • Cost: Free to consumers (plan pays review fees)
  • Contact: Illinois Department of Insurance

Illinois-Specific Resources:

  • IDOI Consumer Hotline: 877-527-9431
  • Attorney General Health Care Helpline: 1-877-305-5145
  • Online external review filing: Available through IDOI website

When Illinois patients work with experienced advocates like Counterforce Health, they get assistance navigating both Humana's internal processes and Illinois's external review system, with appeals tailored to state-specific timelines and requirements.

Pre-Submission Checklist

Before submitting your StrataGraft prior authorization:

Clinical Documentation:

  • ICD-10 codes for burn type, depth, and location
  • Wound measurements and photographs
  • Documentation of burn etiology (thermal)
  • Prior treatment history and outcomes
  • Surgical plan and estimated units needed

Billing Information:

  • HCPCS J7353 with correct unit calculation
  • Appropriate modifiers (-JW for wastage, etc.)
  • Medical benefit billing pathway confirmed
  • Provider NPI and facility information

Administrative Requirements:

  • Current Humana PA form completed
  • All required attachments included
  • Submission method confirmed (portal/fax)
  • Follow-up plan for PA status tracking

FAQ

How long does Humana PA take for StrataGraft in Illinois? Standard prior authorization decisions are typically rendered within 15 business days for pre-service requests. Expedited reviews (for urgent cases) must be completed within 24 hours.

What if StrataGraft is subject to step therapy? Starting in 2025, Humana Medicare Advantage may require trying less expensive alternatives first. Document medical necessity for StrataGraft specifically and any contraindications to step therapy options.

Can I request an expedited appeal in Illinois? Yes, both Humana internal appeals and Illinois external reviews offer expedited processes when delays could seriously jeopardize your health. Provide clinical documentation supporting urgency.

What documentation proves medical necessity for StrataGraft? Key evidence includes: deep partial-thickness burn diagnosis, wound measurements, failed standard care, clinical photographs, and evidence that autografting alone is insufficient.

How do I file an external review in Illinois? After exhausting Humana's internal appeals, file with the Illinois Department of Insurance within 4 months of the final denial. Use their online portal or mail/fax the required forms.

What if both facility and physician bill for StrataGraft? This creates duplicate billing issues. Clarify in advance who bills for the product (J7353) versus the application procedure. Only one entity should bill for the StrataGraft units.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Always consult with your healthcare provider and insurance plan for specific coverage decisions. Insurance policies and state regulations may change. For personalized assistance with appeals and prior authorizations, consider consulting with coverage advocates or legal professionals specializing in healthcare access.

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