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

How to Get StrataGraft Covered by UnitedHealthcare in Michigan: Prior Authorization Guide and Appeals Timeline

Quick Answer: Getting StrataGraft Covered by UnitedHealthcare in Michigan

StrataGraft requires prior authorization from UnitedHealthcare as a facility-billed medical benefit (not pharmacy). The fastest path: Submit PA through the UHC Provider Portal with complete burn documentation, wound measurements, and proof that autograft isn't feasible. Standard decisions take up to 15 days; expedited reviews for urgent cases are completed within 72 hours. If denied, you have 180 days for internal appeals and 127 days for Michigan DIFS external review.

First step today: Verify your UnitedHealthcare plan covers facility-administered biologics and gather clinical documentation from your burn center.

Table of Contents

What Affects StrataGraft Approval Timeline

Several factors determine how quickly UnitedHealthcare processes your StrataGraft prior authorization in Michigan:

Benefit Type: StrataGraft is billed as a facility procedure under your medical benefit, not through pharmacy coverage. This means the authorization goes through UnitedHealthcare's medical review team rather than OptumRx, which can affect processing times.

Documentation Completeness: The most significant factor affecting timeline is whether your initial submission includes all required clinical evidence. Incomplete requests trigger additional information requests that can add 7-14 days to the process.

Clinical Complexity: Since StrataGraft is FDA-approved specifically for deep partial-thickness thermal burns in adults when autograft is clinically indicated, reviewers must verify that your case meets these precise criteria.

Plan Type: UnitedHealthcare Medicare Advantage plans may have different review timelines than commercial plans, with Medicare requiring decisions within specific federal timeframes.

Pre-Submission Preparation (0-2 Days)

Before submitting your prior authorization request, gather these essential documents:

Required Clinical Documentation

  • Wound assessment: Detailed measurements, depth evaluation, and clinical photographs
  • Burn severity documentation: Confirmation of deep partial-thickness thermal burns
  • Autograft justification: Clinical notes explaining why autograft is unavailable or contraindicated
  • Patient eligibility: Verification that patient is 18+ years old (FDA requirement)
  • Infection status: Documentation that wound is free of active infection
  • Surgical readiness: Confirmation of complete wound excision with achieved hemostasis

Billing Information Checklist

  • HCPCS code J7353 for StrataGraft
  • Facility NPI and in-network verification
  • Patient insurance details and member ID
  • Treating physician information and burn center credentials
Tip: Contact your UnitedHealthcare provider representative to verify current prior authorization requirements, as policies can change annually.

Submission to Initial Review (1-5 Days)

UnitedHealthcare accepts prior authorization requests through multiple channels:

Submission Methods

  • Online: UnitedHealthcare Provider Portal (fastest processing)
  • Phone: 800-903-5253 for facility services
  • Fax: 855-225-9847 (verify current number with your plan)

What Reviewers Check First

  1. FDA indication compliance: Adult patient with deep partial-thickness thermal burns
  2. Medical necessity: Clinical justification for StrataGraft over alternatives
  3. Provider network status: Confirmation that facility and physician are in-network
  4. Benefit coverage: Verification that facility procedures are covered under the member's plan

Michigan-Specific Note: UnitedHealthcare typically processes standard prior authorizations within 15 business days, though urgent cases may qualify for expedited 72-hour review.

Additional Information Requests (1-7 Days)

If UnitedHealthcare requests additional information, respond promptly to avoid delays:

Common Additional Requests

  • Enhanced clinical photographs showing burn depth and extent
  • Detailed surgical plan including timing and technique
  • Prior treatment documentation showing conservative management attempts
  • Specialist consultation notes from burn center physicians

How to Respond Quickly

Submit additional information through the same portal or fax number used for the original request. Include your original prior authorization reference number and clearly label all documents.

Note: Additional information requests don't restart the review clock—UnitedHealthcare continues counting from the original submission date.

Decision Window and Outcomes

UnitedHealthcare will issue one of three decisions:

Approval

  • Full approval: StrataGraft authorized as requested
  • Partial approval: Authorized with specific conditions or quantity limits
  • Approval letters include authorization numbers, valid dates, and any restrictions

Denial

  • Denial letters specify exact reasons and required documentation for appeals
  • Common denial reasons: Outside FDA indication, insufficient documentation, or missing autograft justification

Pending

  • Additional review needed: May require peer-to-peer consultation or specialist review
  • Timeline extension: UnitedHealthcare may request additional time for complex cases

If Denied: Appeals Process in Michigan

Michigan patients have robust appeal rights under state law:

Internal Appeals (UnitedHealthcare)

  • Timeline: 180 days from denial date to file
  • Levels: Typically 1-2 internal review levels
  • Expedited option: 72 hours for urgent medical needs
  • Submit via: UnitedHealthcare member portal or provider portal

External Review (Michigan DIFS)

If internal appeals fail, Michigan's Department of Insurance and Financial Services (DIFS) provides independent review:

  • Timeline: 127 days from final internal denial to file external review
  • Process: Complete DIFS External Review Request form
  • Expedited review: 72 hours for urgent cases with physician certification
  • Contact: 877-999-6442 or michigan.gov/DIFS
  • Outcome: DIFS decisions are binding on UnitedHealthcare

Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals. Their platform analyzes denial letters and plan policies to draft point-by-point rebuttals aligned to each insurer's specific requirements, potentially saving months in the appeals process.

Timeline Visual: Key Milestones

Phase Timeline Action Required Expected Outcome
Pre-submission 0-2 days Gather documentation Complete clinical file
Initial submission 1 day Submit via portal/fax Confirmation received
Initial review 5-15 days Wait for decision Approval, denial, or info request
Additional info (if needed) 1-7 days Submit requested docs Review continues
Final decision 15-30 days total Receive determination Proceed or appeal
Internal appeal 30-60 days Submit appeal documents Overturn or uphold denial
External review (MI) 30-60 days DIFS independent review Final binding decision

Common Denial Reasons & How to Fix Them

Denial Reason How to Overturn Required Documentation
"Outside FDA indication" Confirm adult patient with deep partial-thickness thermal burns Age verification, burn depth assessment
"Autograft preferred" Document why autograft unavailable/contraindicated Clinical notes, patient condition assessment
"Insufficient documentation" Submit complete clinical file Photos, measurements, surgical notes
"Not medically necessary" Provide evidence-based justification Literature support, clinical guidelines
"Experimental/investigational" Cite FDA approval status FDA labeling, approved indication

Clinician Corner: Medical Necessity Documentation

Essential Elements for Medical Necessity Letter

  1. Patient demographics: Age 18+ with specific burn characteristics
  2. Clinical presentation: Deep partial-thickness thermal burn documentation
  3. Treatment rationale: Why StrataGraft is appropriate for this patient
  4. Alternative considerations: Why autograft isn't feasible or optimal
  5. Expected outcomes: Treatment goals and monitoring plan

Supporting Evidence to Include

  • FDA labeling: StrataGraft approved indication and patient population
  • Clinical studies: Peer-reviewed evidence supporting efficacy
  • Burn center protocols: Institution-specific treatment guidelines
  • Patient-specific factors: Comorbidities, wound characteristics, surgical timing
From our advocates: "We've seen StrataGraft approvals succeed when burn centers clearly document that the patient meets FDA criteria and explain why traditional autograft isn't optimal. The key is connecting clinical facts to UnitedHealthcare's coverage policy requirements—not just stating medical necessity, but proving it with their own criteria."

FAQ: StrataGraft Coverage Questions

Q: How long does UnitedHealthcare prior authorization take for StrataGraft in Michigan? A: Standard prior authorizations typically take up to 15 business days. Expedited reviews for urgent cases are completed within 72 hours when medical necessity is documented.

Q: Is StrataGraft covered under pharmacy or medical benefits? A: StrataGraft is covered under medical benefits as a facility-administered procedure, not through pharmacy coverage. It's billed using HCPCS code J7353.

Q: What if my burn center isn't in UnitedHealthcare's network? A: Out-of-network facilities must obtain prior authorization for all services. You may also request a network adequacy exception if no in-network burn centers are available within reasonable distance.

Q: Can I appeal a StrataGraft denial in Michigan? A: Yes. You have 180 days for UnitedHealthcare internal appeals, followed by 127 days to file external review with Michigan DIFS if internal appeals fail.

Q: Does step therapy apply to StrataGraft? A: Step therapy requirements vary by plan, but StrataGraft's specific FDA indication for deep partial-thickness burns when autograft is clinically indicated may qualify for exceptions.

Q: What documentation do I need for an expedited appeal? A: Expedited appeals require physician certification that standard timeline could jeopardize the patient's health, plus all standard clinical documentation supporting medical necessity.

For complex cases requiring expert appeal assistance, Counterforce Health helps patients and clinicians navigate insurance denials by creating targeted rebuttals based on each payer's specific coverage policies and clinical requirements.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage policies and appeal procedures may change. Always verify current requirements with UnitedHealthcare and consult your healthcare provider for medical decisions. For personalized assistance with insurance appeals, consider consulting with healthcare coverage specialists or legal professionals experienced in insurance matters.

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