By Counterforce Health Team in Ultomiris (ravulizumab) —

How to Get Ultomiris (Ravulizumab) Covered by Humana in Texas: Coding, Appeals, and Prior Authorization Guide

Answer Box: Getting Ultomiris Covered by Humana in Texas

Ultomiris (ravulizumab) requires prior authorization from Humana Medicare Advantage plans in Texas. The fastest path to approval: 1) Submit PA request through Humana's provider portal with diagnosis-specific ICD-10 codes (D59.5 for PNH, D59.3 for aHUS, G70.0 for myasthenia gravis, G36.0 for NMOSD), 2) Include meningococcal vaccination records and clinical documentation supporting medical necessity, 3) Use HCPCS code J1303 for billing (10 mg units). Appeals must be filed within 65 days if denied. Start today: Verify your specific plan's PA requirements using Humana's Prior Authorization Search Tool.

Table of Contents

  1. Coverage Overview: Medical vs. Pharmacy Benefit
  2. ICD-10 Diagnosis Codes for Ultomiris
  3. HCPCS Billing and NDC Requirements
  4. Prior Authorization Process with Humana
  5. Common Denial Reasons and Solutions
  6. Texas Appeals Process
  7. Pre-Submission Checklist
  8. FAQ

Coverage Overview: Medical vs. Pharmacy Benefit

Ultomiris (ravulizumab) is covered under Medicare Part B (medical benefit) for Humana Medicare Advantage members, not the Part D pharmacy benefit. This means the drug is administered in an infusion center or physician office and billed using medical claim forms rather than through retail pharmacies.

Coverage at a Glance

Requirement Details Where to Verify
Prior Authorization Required for most Humana MA plans Humana PA Search Tool
Formulary Status Medical benefit (Part B equivalent) Plan-specific formulary documents
Site of Care Infusion center, hospital outpatient, physician office Provider contract terms
Meningococcal Vaccination Required before treatment FDA REMS requirements
Appeals Deadline 65 days from denial notice Medicare regulations
Note: New Humana members already on Ultomiris may continue therapy for 90 days without PA under continuity-of-care provisions, but should initiate PA requests immediately for ongoing coverage.

ICD-10 Diagnosis Codes for Ultomiris

Accurate diagnosis coding is critical for Ultomiris approval. Use these specific ICD-10-CM codes based on the patient's condition:

Primary Diagnosis Codes

Paroxysmal Nocturnal Hemoglobinuria (PNH)

  • D59.5 - Paroxysmal nocturnal hemoglobinuria [Marchiafava-Micheli]
  • Documentation should include flow cytometry results showing PNH clone size

Atypical Hemolytic Uremic Syndrome (aHUS)

  • D59.3 - Hemolytic-uremic syndrome
  • Include complement testing results and exclusion of STEC-HUS

Generalized Myasthenia Gravis (gMG)

  • G70.00 - Myasthenia gravis without (acute) exacerbation
  • G70.01 - Myasthenia gravis with (acute) exacerbation
  • Medical record must document AChR-antibody positivity and generalized symptoms

Neuromyelitis Optica Spectrum Disorder (NMOSD)

  • G36.0 - Neuromyelitis optica [Devic]
  • Documentation should confirm AQP4-IgG positivity
Tip: Ensure the diagnosis code matches the FDA-approved indication exactly. Off-label uses often trigger automatic denials requiring peer-to-peer review.

HCPCS Billing and NDC Requirements

HCPCS J-Code and Unit Calculation

Ultomiris uses HCPCS code J1303 (Injection, ravulizumab-cwvz, 10 mg). Calculate billing units by dividing the total dose by 10 mg:

  • Loading dose (3,000-3,600 mg): 300-360 units
  • Maintenance dose (3,600 mg): 360 units every 8 weeks

NDC Codes and Modifiers

Required NDC Codes:

  • 300 mg/3 mL vial: 25682-0025-01
  • 1,100 mg/11 mL vial: 25682-0028-01

Required Modifiers:

  • JZ - Zero drug amount discarded
  • RE - REMS compliance documented

Administration Coding

Bill infusion administration separately using:

  • 96365 - Initial IV infusion (up to 1 hour)
  • 96366 - Each additional hour (if applicable)

Prior Authorization Process with Humana

Step-by-Step PA Submission

1. Verify PA Requirement (Provider)

2. Gather Required Documentation (Clinic)

  • Diagnosis confirmation with appropriate lab results
  • Meningococcal vaccination records or prophylaxis plan
  • Prior therapy history and outcomes
  • Weight-based dosing calculation
  • Clinical notes supporting medical necessity

3. Submit PA Request (Provider)

  • Use Humana's electronic prior authorization (ePA) portal when possible
  • Include all supporting documentation
  • Expected timeline: 1-3 business days for complete electronic submissions

4. Follow Up (Patient/Clinic)

  • Track request status through provider portal
  • Prepare for potential peer-to-peer review
Clinician Corner: Medical necessity letters should address: confirmed diagnosis with lab values, previous treatments and why they failed or were contraindicated, specific clinical goals (e.g., hemolysis control in PNH, relapse prevention in NMOSD), and planned monitoring approach.

Common Denial Reasons and Solutions

Denial Reason Solution Required Documentation
Insufficient diagnosis documentation Submit complete lab workup Flow cytometry (PNH), complement studies (aHUS), antibody testing (gMG/NMOSD)
Missing vaccination records Provide immunization documentation Meningococcal vaccine dates or prophylaxis plan
Step therapy not met Document eculizumab trial/failure Treatment records, adverse events, efficacy data
Dosing exceeds guidelines Justify weight-based calculation Patient weight, FDA dosing chart, clinical rationale
Concurrent complement inhibitor use Clarify treatment plan Medication list, transition timeline

Texas Appeals Process

Internal Appeal (Redetermination)

Timeline: Must file within 65 days of denial notice Decision Timeline:

  • Part D appeals: 7 days
  • Part C (medical): 30 days (pre-service), 60 days (post-service)

How to File:

  1. Complete Humana's appeal form
  2. Include prescriber's medical necessity letter
  3. Submit via member portal, fax, or mail
  4. Request expedited review if health is at risk

External Review (Texas IRO)

If internal appeal is denied, Texas law provides access to Independent Review Organizations (IRO) through the Texas Department of Insurance.

Timeline: Request within 4 months of final internal denial Decision Timeline:

  • Urgent cases: 5 days
  • Standard cases: 20 days

Contact Information:

  • Texas Department of Insurance: 1-800-252-3439
  • IRO information line: 1-866-554-4926
Important: The IRO decision is binding on Humana if they overturn the denial.

Pre-Submission Checklist

Documentation Verification:

  • Correct ICD-10 code for patient's condition
  • Lab results confirming diagnosis
  • Meningococcal vaccination records
  • Prior therapy documentation
  • Weight and dosing calculations
  • REMS program enrollment

Billing Code Accuracy:

  • J1303 HCPCS code
  • Correct NDC for vial strength used
  • JZ and RE modifiers included
  • Unit calculation verified (dose ÷ 10)

Submission Requirements:

  • PA request submitted before first infusion
  • All supporting documents attached
  • Provider contact information current
  • Member ID and demographics verified

FAQ

How long does Humana prior authorization take for Ultomiris in Texas? Standard PA decisions typically take 1-3 business days for complete electronic submissions. Expedited requests for urgent medical situations are processed within 24-72 hours.

What if Ultomiris is not on Humana's formulary? Since Ultomiris is billed under the medical benefit (Part B), formulary status is less relevant. However, you may need to request a formulary exception if the plan has specific coverage restrictions.

Can I appeal if I'm denied step therapy requirements? Yes. Document why eculizumab (Soliris) is inappropriate, including adverse effects, lack of efficacy, or contraindications. Include clinical notes and treatment records.

Does Humana cover the subcutaneous version of Ultomiris? The subcutaneous formulation may have different coverage criteria. Verify with Humana's PA team and ensure you're using the correct administration codes.

What happens if I miss the 65-day appeal deadline? You may request a late filing exception if you can demonstrate good cause for the delay, such as not receiving the denial notice or serious illness preventing timely filing.

Who can help me navigate the appeals process in Texas? Contact the Texas Department of Insurance (1-800-252-3439), Office of Public Insurance Counsel (1-877-611-6742), or Disability Rights Texas for assistance with complex cases.

About Counterforce Health

Counterforce Health specializes in turning insurance denials into successful appeals for patients, clinicians, and specialty pharmacies. Our platform analyzes denial letters, plan policies, and clinical notes to create targeted, evidence-backed appeals that align with each payer's specific requirements. We help streamline the prior authorization process and improve approval rates for complex specialty medications like Ultomiris.

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 Humana and consult with healthcare providers regarding treatment decisions. For personalized assistance with insurance appeals in Texas, consider consulting with Counterforce Health or other qualified advocacy services.

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