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

How to Get StrataGraft Covered by UnitedHealthcare in North Carolina: Complete Prior Authorization and Appeals Guide

Answer Box: Getting StrataGraft Covered by UnitedHealthcare in North Carolina

StrataGraft requires prior authorization from UnitedHealthcare as a facility-billed medical benefit (not pharmacy) for deep partial-thickness thermal burns. Start by having your burn specialist submit complete documentation through the UnitedHealthcare Provider Portal. If denied, you have 180 days for internal appeals and can access North Carolina's Smart NC external review program for independent assessment. First step: ensure your burn center has complete wound measurements, clinical photos, and medical necessity justification ready before submitting.

Table of Contents

  1. Understanding StrataGraft Coverage Requirements
  2. Prior Authorization Process
  3. Common Denial Reasons and How to Fix Them
  4. Internal Appeals Process
  5. North Carolina Smart NC External Review
  6. Appeal Templates and Scripts
  7. When to Escalate
  8. FAQ

Understanding StrataGraft Coverage Requirements

StrataGraft (allogeneic cultured keratinocytes and fibroblasts in murine collagen-dsat) is a tissue-engineered treatment for deep partial-thickness thermal burns in adults. UnitedHealthcare covers this therapy under specific medical criteria, but it requires careful documentation and proper billing procedures.

Coverage at a Glance

Requirement Details Documentation Needed Source
Age 18 years or older Patient ID and birth date FDA Label
Diagnosis Deep partial-thickness thermal burns ICD-10 codes, clinical assessment UHC Policy
Prior Authorization Required Complete PA submission UHC Provider Portal
Billing Method Facility medical benefit HCPCS J7353 per cm² UHC Policy
Appeals Deadline 180 days from denial Internal appeal forms UHC Member Services

Prior Authorization Process

Step-by-Step: Fastest Path to Approval

  1. Confirm Patient Eligibility (Burn Center)
    • Verify deep partial-thickness burns with intact dermal elements
    • Document patient age ≥18 years
    • Timeline: Same day as assessment
  2. Gather Required Documentation (Clinical Team)
    • Complete wound measurements in square centimeters
    • Clinical photographs with measurement scale
    • Surgical consultation notes confirming need for grafting
    • Timeline: 1-2 business days
  3. Submit Prior Authorization (Provider)
    • Use UnitedHealthcare Provider Portal
    • Include all clinical documentation
    • Bill using HCPCS code J7353
    • Timeline: Submit within 24-48 hours of decision to treat
  4. Track Authorization Status (Office Staff)
    • Standard review: up to 15 business days
    • Expedited review: within 72 hours for urgent cases
    • Check portal daily for status updates

Required Clinical Documentation

Your burn specialist must provide comprehensive documentation including:

Medical Necessity Checklist:

  • Diagnosis confirmation with ICD-10 codes
  • Burn depth assessment (deep partial-thickness)
  • Total body surface area (TBSA) calculations
  • Clinical photographs showing burn characteristics
  • Documentation that wound is infection-free
  • Surgical plan detailing StrataGraft application
  • Justification for why autograft is not feasible
Clinician Corner: Include specific contraindications to autograft such as insufficient donor sites, patient instability, or medical comorbidities that preclude harvesting. Reference burn treatment guidelines from the American Burn Association when available.

Common Denial Reasons and How to Fix Them

Denial Reason How to Overturn Required Documentation
"Not medically necessary" Provide detailed burn assessment Clinical photos, wound measurements, burn depth confirmation
"Outside FDA indication" Confirm patient meets all criteria Age verification, diagnosis codes, burn classification
"Insufficient documentation" Submit complete clinical package All items from medical necessity checklist
"Autograft preferred" Document contraindications Medical reasons why autograft cannot be used
"Experimental/investigational" Reference FDA approval FDA approval letter, clinical guidelines

Internal Appeals Process

If your prior authorization is denied, UnitedHealthcare provides a structured appeals process with specific timelines and requirements.

Appeals Timeline for North Carolina

  • File Internal Appeal: Within 180 days of denial date
  • First-Level Review: 30 days for standard, 72 hours for expedited
  • Second-Level Review: 30 days for standard, 72 hours for expedited
  • External Review Access: After completing internal appeals

What to Include in Your Appeal

Essential Components:

  1. Cover Letter stating you're appealing the denial
  2. Medical Necessity Letter from your burn specialist
  3. Updated Clinical Documentation addressing denial reasons
  4. Supporting Literature (FDA approval, clinical studies)
  5. Patient Impact Statement describing urgency of need

Medical Necessity Letter Template:

[Date]
UnitedHealthcare Appeals Department

Re: Appeal for StrataGraft Coverage - Member [ID]

This letter serves as a formal appeal for coverage of StrataGraft for [Patient Name], who has been denied coverage for treatment of deep partial-thickness thermal burns.

Clinical Justification:
- Patient meets FDA criteria: [age, diagnosis, burn characteristics]
- Autograft is contraindicated due to: [specific medical reasons]
- StrataGraft is medically necessary because: [clinical rationale]
- Expected outcomes: [healing timeline, functional preservation]

Attached documentation includes: [list all supporting materials]

Sincerely,
[Physician Name and Credentials]

North Carolina Smart NC External Review

If UnitedHealthcare upholds their denial after internal appeals, North Carolina residents can request an independent external review through Smart NC, the state's consumer assistance program.

Smart NC External Review Process

Eligibility Requirements:

  • Completed UnitedHealthcare's internal appeals process
  • State-regulated insurance plan (not self-funded employer plans)
  • Denial based on medical necessity or experimental treatment determination
  • Request filed within 120 days of final internal denial

How to Request External Review:

  1. Contact Smart NC: Call 1-855-408-1212 for assistance
  2. Submit Application: Complete external review request form
  3. Provide Documentation: Include denial letters and clinical records
  4. Independent Review: Assigned to rotating Independent Review Organization (IRO)

Timeline for External Review:

  • Standard Review: Decision within 45 days
  • Expedited Review: Decision within 72 hours for urgent cases
  • Ultra-Urgent: 24-72 hours for life-threatening situations
Note: Smart NC staff can help you complete the external review application and gather supporting documentation, though they cannot serve as your official representative.

For patients and families dealing with complex insurance denials, Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals. Their platform analyzes denial letters and plan policies to create point-by-point rebuttals aligned with each insurer's specific requirements, helping patients access critical treatments like StrataGraft more efficiently.

When External Review Overturns Denials

If the IRO rules in your favor:

  • UnitedHealthcare must provide coverage within 3 business days
  • Decision is binding on the insurance company
  • No additional appeals needed through insurance

Appeal Templates and Scripts

Patient Phone Script for UnitedHealthcare

"Hello, I'm calling about a prior authorization denial for StrataGraft treatment. My member ID is [number]. I received a denial letter dated [date] and want to file an internal appeal. Can you please:

  1. Confirm the specific reasons for denial
  2. Provide the appeals mailing address and fax number
  3. Tell me what additional documentation you need
  4. Confirm the deadline for submitting my appeal"

Clinic Staff Script for Peer-to-Peer Review

"I'm requesting a peer-to-peer review for [Patient Name] regarding StrataGraft coverage denial. The patient has deep partial-thickness burns requiring surgical intervention, and autograft is contraindicated due to [specific reasons]. When can we schedule a clinical discussion with the medical director?"

When to Escalate

File a Complaint with North Carolina Regulators

Contact the North Carolina Department of Insurance if:

  • UnitedHealthcare doesn't respond within required timeframes
  • You suspect improper denial practices
  • Appeals process isn't followed correctly

NC Department of Insurance Consumer Services

  • Phone: 1-855-408-1212 (Smart NC)
  • Website: ncdoi.gov
  • Online complaint system available

Additional Resources

Throughout the appeals process, organizations like Counterforce Health can provide specialized support by analyzing your specific denial and creating customized appeals that address UnitedHealthcare's policy requirements point-by-point, potentially improving your chances of approval.

FAQ

How long does UnitedHealthcare prior authorization take for StrataGraft in North Carolina? Standard reviews take up to 15 business days. Expedited reviews for urgent cases are completed within 72 hours. Incomplete documentation can add 7-14 days to processing time.

What if StrataGraft is considered experimental by UnitedHealthcare? StrataGraft has FDA approval for deep partial-thickness thermal burns. Include the FDA approval documentation and clinical studies in your appeal to counter experimental/investigational denials.

Can I request an expedited appeal in North Carolina? Yes, both UnitedHealthcare and Smart NC offer expedited reviews for urgent medical situations. Your physician must certify that delays would jeopardize your health or recovery.

Does step therapy apply to StrataGraft coverage? UnitedHealthcare may require documentation that standard burn treatments (like autograft) are not appropriate before approving StrataGraft. This isn't traditional step therapy but requires clinical justification.

What happens if Smart NC external review denies my appeal? The IRO decision is binding, ending the administrative appeals process. You may still have legal options, but would need to consult with an attorney specializing in insurance law.

How much does StrataGraft cost without insurance? StrataGraft is an institutional facility-billed product without published retail pricing. Costs vary by hospital and are typically billed per square centimeter of treatment area.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage decisions depend on your specific insurance plan and medical circumstances. Always consult with your healthcare provider and insurance company for personalized guidance. For additional support with insurance appeals, contact Smart NC at 1-855-408-1212 or visit ncdoi.gov.

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