By Counterforce Health Team in Strensiq (asfotase alfa) —

How to Get Strensiq (Asfotase Alfa) Covered by Blue Cross Blue Shield in Georgia: Complete Coding, Appeals, and Authorization Guide

Answer Box: Getting Strensiq Covered by Blue Cross Blue Shield in Georgia

Blue Cross Blue Shield Georgia requires prior authorization for Strensiq (asfotase alfa) with strict criteria for pediatric-onset hypophosphatasia. Success requires proper coding (ICD-10 E83.39, HCPCS J3590), comprehensive clinical documentation from a specialist, and evidence of low alkaline phosphatase with skeletal/dental symptoms. If denied, Georgia's external review process through the Department of Insurance provides a binding second opinion within 30 days.

First step today: Contact your endocrinologist or metabolic specialist to initiate the prior authorization request through the BCBS Georgia provider portal or CoverMyMeds platform.

Table of Contents

  1. Coding Basics: Medical vs. Pharmacy Benefit Paths
  2. ICD-10 Mapping for Hypophosphatasia
  3. Product Coding: HCPCS, NDC, and Units
  4. Clean Prior Authorization Request
  5. Common Coding Pitfalls to Avoid
  6. BCBS Georgia Verification Process
  7. Pre-Submission Audit Checklist
  8. Appeals Strategy for Georgia
  9. Cost Support and Resources
  10. FAQ

Coding Basics: Medical vs. Pharmacy Benefit Paths

Strensiq coverage depends on whether your Blue Cross Blue Shield Georgia plan processes it under the medical benefit (administered in clinic) or pharmacy benefit (home self-injection). Most pediatric patients receive Strensiq under the medical benefit due to initial supervision requirements and anaphylaxis risk monitoring.

Coverage Pathways

Benefit Type Typical Setting Prior Auth Required Billing Code
Medical Benefit Clinic/hospital administration Yes - clinical review HCPCS J3590
Pharmacy Benefit Home self-injection Yes - pharmacy review NDC-based
Note: BCBS Georgia typically covers Strensiq under medical benefit for initial doses due to FDA boxed warning requirements for anaphylaxis monitoring.

ICD-10 Mapping for Hypophosphatasia

Primary diagnosis code: E83.39 (Other disorders of phosphorus metabolism)

This code specifically captures hypophosphatasia and is recognized by CDC ICD-10-CM for billing purposes.

Documentation Requirements for E83.39

Your medical records must include:

  • Confirmed diagnosis of hypophosphatasia with genetic testing or characteristic clinical presentation
  • Age of symptom onset (perinatal, infantile, juvenile, or adult)
  • Laboratory evidence: Persistently low serum alkaline phosphatase below age/sex norms
  • Clinical manifestations: Premature tooth loss, fractures, skeletal deformities, or respiratory issues
  • Radiographic findings: Evidence of rickets, osteomalacia, or craniosynostosis
Clinician Tip: Include elevated substrate levels (pyridoxal 5'-phosphate, phosphoethanolamine) in documentation to strengthen the biochemical diagnosis.

Product Coding: HCPCS, NDC, and Units

HCPCS Coding

Primary code: J3590 (Unclassified biologics)

Strensiq does not have a permanent, product-specific J-code as of 2024. Most payers, including BCBS Georgia, accept J3590 for billing purposes.

NDC Codes and Vial Strengths

Vial Strength NDC Code (Single) NDC Code (12-pack)
18 mg/0.45 mL 25682-0010-01 25682-0010-12
28 mg/0.7 mL 25682-0013-01 25682-0013-12
40 mg/1 mL 25682-0016-01 25682-0016-12
80 mg/0.8 mL 25682-0019-01 25682-0019-12

Dosing and Unit Calculations

Billing units = number of vials administered (not milligrams)

  • Perinatal/Infantile HPP: Up to 9 mg/kg/week divided into 3+ doses
  • Juvenile HPP: Up to 6 mg/kg/week divided into 3+ doses

Example calculation for 20 kg child with juvenile HPP:

  • Weekly dose: 6 mg/kg × 20 kg = 120 mg/week
  • Divided TIW: 40 mg per dose
  • Vials needed: One 40 mg vial per dose = 3 billing units per week

Clean Prior Authorization Request

Required Documentation Checklist

Clinical Information:

  • Specialist consultation note (endocrinologist or metabolic specialist)
  • Confirmed diagnosis with ICD-10 E83.39
  • Laboratory results showing low alkaline phosphatase
  • Radiographic evidence of skeletal involvement
  • Documentation of age of onset (pediatric-onset required)

Administrative Details:

  • Patient demographics and insurance information
  • Prescriber NPI and DEA numbers
  • Requested dosing regimen with weight-based calculations
  • NDC codes for specific vial strengths needed
  • Place of service (clinic vs. home administration)

Sample Medical Necessity Statement

"This 8-year-old patient has confirmed juvenile-onset hypophosphatasia with genetic testing showing ALPL mutation, persistently low alkaline phosphatase (15 U/L, normal 145-420), and radiographic evidence of rickets. Standard supportive care has been insufficient to prevent progressive skeletal deformities and fractures. Strensiq represents the only FDA-approved disease-modifying therapy for pediatric-onset HPP."

Common Coding Pitfalls to Avoid

Unit Conversion Errors

  • Wrong: Billing fractional vial units (e.g., 0.5 units for half-dose)
  • Right: Bill only whole vials administered, even if dose requires partial vial

Mismatched Benefit Categories

  • Wrong: Submitting medical benefit claim with pharmacy NDC-only coding
  • Right: Use appropriate HCPCS (J3590) for medical benefit claims

Missing Onset Documentation

  • Wrong: General "hypophosphatasia" diagnosis without age specification
  • Right: Clear documentation of "juvenile-onset hypophosphatasia" or similar pediatric-onset terminology

Inadequate Specialist Support

  • Wrong: Primary care provider initiating Strensiq request
  • Right: Endocrinologist, geneticist, or metabolic specialist as primary prescriber

BCBS Georgia Verification Process

Pre-Authorization Verification Steps

  1. Check formulary status via BCBS Georgia provider portal
  2. Confirm prior authorization requirements for member's specific plan
  3. Verify in-network specialist for prescribing requirements
  4. Review medical vs. pharmacy benefit coverage for member's plan design

Submission Channels

  • Electronic: CoverMyMeds platform (preferred)
  • Fax: Numbers provided in denial letters or provider portal
  • Phone: Expedited reviews available for urgent cases
Important: BCBS Georgia typically processes standard prior authorizations within 15 calendar days, with expedited reviews completed in 72 hours for urgent medical situations.

Pre-Submission Audit Checklist

Clinical Documentation Review:

  • Diagnosis clearly states pediatric-onset hypophosphatasia
  • Laboratory values show age-appropriate alkaline phosphatase deficiency
  • Clinical symptoms documented with functional impact
  • Specialist evaluation and recommendation included

Coding Verification:

  • ICD-10 E83.39 matches clinical documentation
  • HCPCS J3590 appropriate for medical benefit
  • NDC codes match requested vial strengths
  • Dosing calculations show weight-based rationale

Administrative Completeness:

  • All required forms signed and dated
  • Provider credentials and contact information current
  • Member eligibility verified for date of service
  • Prior authorization number obtained before administration

Appeals Strategy for Georgia

If your initial prior authorization is denied, Georgia law provides multiple appeal levels with specific timelines.

Internal Appeals Process

Level 1: Standard Internal Appeal

  • Timeline: 15 calendar days for standard review
  • Submission: Written request with additional clinical documentation
  • Required: Point-by-point response to denial reasons

Level 2: Peer-to-Peer Review

  • Timeline: Can be requested during or after Level 1
  • Process: Treating specialist discusses case directly with BCBS medical director
  • Advantage: Real-time clarification of clinical rationale

External Review Through Georgia Department of Insurance

If internal appeals fail, Georgia law provides binding external review through independent medical experts.

External Review Process:

From our advocates: "We've seen several successful Strensiq appeals in Georgia where the external reviewer focused on the lack of alternative treatments for pediatric HPP and the FDA's specific approval for this indication. The key was providing peer-reviewed evidence showing Strensiq's unique mechanism of action as enzyme replacement therapy."

Appeal Success Strategies

  1. Address each denial reason specifically with clinical evidence
  2. Include peer-reviewed literature supporting Strensiq's efficacy in HPP
  3. Emphasize lack of alternatives for pediatric-onset disease
  4. Reference FDA approval and labeling for your specific indication
  5. Document functional improvements or prevention of deterioration

Cost Support and Resources

Manufacturer Support Programs

Alexion OneSource™

Strensiq Access Navigator

Financial Assistance Options

  • Commercial insurance copay assistance (income restrictions may apply)
  • Foundation grants for eligible patients
  • State pharmaceutical assistance programs (verify Georgia eligibility)

FAQ

How long does BCBS Georgia prior authorization take for Strensiq? Standard reviews take up to 15 calendar days. Expedited reviews for urgent medical situations are completed within 72 hours.

What if Strensiq is non-formulary on my plan? Non-formulary medications can still be covered through formulary exceptions. Submit clinical documentation showing medical necessity and lack of formulary alternatives.

Can I request an expedited appeal in Georgia? Yes, if delays in treatment could seriously jeopardize your health. Mark all submissions as "URGENT" and provide clinical justification for expedited review.

Does step therapy apply to Strensiq? Most BCBS plans recognize that no alternative treatments exist for hypophosphatasia, but some may require documentation of failed supportive therapies.

What happens if my external review is approved? BCBS Georgia is legally required to cover the approved treatment. The external review decision is binding on the insurer.

Can adults get Strensiq coverage? Coverage is typically limited to patients with pediatric-onset disease (symptoms before age 18). Adult-onset HPP is generally excluded.

Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals for complex medications like Strensiq. Our platform analyzes denial letters, identifies specific policy criteria, and helps patients and providers build comprehensive appeals that address each denial reason with the right clinical evidence and regulatory support. For patients facing Strensiq denials in Georgia, we provide the tools and expertise to navigate both internal appeals and the state's external review process effectively.

Sources & Further Reading

Legal Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage decisions vary by individual plan and medical circumstances. Always consult with your healthcare provider and insurance company for specific coverage determinations. For personalized assistance with insurance appeals and prior authorization, visit www.counterforcehealth.org to learn how our platform can help strengthen your case with targeted, evidence-based appeal strategies.

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