By Counterforce Health Team in Crysvita (burosumab) —

Myths vs. Facts: Getting Crysvita (burosumab) Covered by Humana in Florida – Prior Authorization & Appeals Guide

Answer Box: Getting Crysvita (burosumab) Covered by Humana in Florida

Quick Facts: Humana requires prior authorization for Crysvita (burosumab) with step therapy through oral phosphate plus vitamin D analogs first. The fastest path: (1) Get your endocrinologist to document failed conventional therapy and genetic/biochemical XLH confirmation, (2) Submit Humana's Medicare Part D coverage determination form via fax (877-486-2621), and (3) Include a detailed serum phosphorus monitoring plan. Standard decisions take 72 hours; appeals must be filed within 65 days in Florida.

Table of Contents

Why Myths Persist About Crysvita Coverage

Misinformation about getting Crysvita (burosumab) covered by Humana spreads quickly, especially among families dealing with X-linked hypophosphatemia (XLH). The drug's high cost—ranging from $4,000 to $40,000+ per vial depending on strength—combined with complex prior authorization requirements creates fertile ground for confusion.

Many patients receive conflicting advice from well-meaning support groups, outdated information from previous appeals, or assumptions based on other insurers' policies. The reality? Humana's specific requirements are clearly documented but frequently misunderstood.

Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into targeted, evidence-backed appeals by identifying the specific denial basis and drafting point-by-point rebuttals aligned to each plan's own rules. Rather than relying on generic templates, the platform pulls the right citations and weaves them into appeals with the required clinical facts for each payer's workflow.

Common Myths vs. Facts

Myth #1: "If my endocrinologist prescribes Crysvita, Humana has to cover it automatically."

Fact: Humana requires prior authorization for all Crysvita prescriptions, regardless of prescriber specialty. The drug appears on Humana's 2025 Medicare Prior Authorization List with mandatory step therapy requirements.

Myth #2: "I can skip the oral phosphate trial if I have genetic confirmation of XLH."

Fact: Even with confirmed PHEX mutations, Humana's policy requires documentation of failure, intolerance, or contraindication to conventional therapy (oral phosphate plus vitamin D analogs) for at least 12 months before approving Crysvita.

Myth #3: "Humana covers Crysvita the same way in every state."

Fact: While Medicare Part D rules are federal, Florida residents have specific appeal rights and external review processes. Florida's Division of Consumer Services (1-877-693-5236) provides state-specific assistance that may not be available elsewhere.

Myth #4: "If Humana denies my first request, I should just pay out of pocket."

Fact: Humana's Medicare Advantage PA denial rate is only ~3.5% (among the lowest of major plans), and appeals frequently succeed when proper documentation is provided. You have 65 days to file an internal appeal with additional external review options in Florida.

Myth #5: "I need to see a Humana-contracted endocrinologist for approval."

Fact: Any qualified endocrinologist, nephrologist, or metabolic bone specialist can prescribe Crysvita and submit prior authorization requests to Humana, regardless of network status. However, using in-network providers may reduce your out-of-pocket costs.

Myth #6: "Crysvita isn't covered because it's too expensive."

Fact: Cost alone doesn't determine coverage. Humana covers many high-cost specialty drugs when medical necessity criteria are met. The key is proper documentation of diagnosis, failed alternatives, and monitoring plans.

Myth #7: "I can use oral phosphate supplements while taking Crysvita."

Fact: This is dangerous and will result in automatic denial. FDA labeling explicitly prohibits concomitant use of oral phosphate and active vitamin D analogs with Crysvita due to risk of nephrocalcinosis and nephrolithiasis.

What Actually Influences Approval

Primary Coverage Criteria

Humana's approval decisions focus on four key areas:

1. Confirmed Diagnosis

  • Documented XLH with PHEX mutation OR
  • Biochemical evidence: low serum phosphate + elevated FGF23 + renal phosphate wasting
  • Tumor-induced osteomalacia (TIO) with unresectable tumor

2. Step Therapy Completion

  • Trial of oral phosphate plus calcitriol/alfacalcidol for ≥12 months
  • Documented failure (persistent low phosphate, continued symptoms) OR
  • Intolerance (GI upset, nephrocalcinosis) OR
  • Clear contraindication

3. Safety Requirements

  • Age ≥1 year (FDA labeling requirement)
  • Adequate kidney function (no severe renal impairment/ESRD)
  • Serum phosphate below normal range at initiation
  • Oral phosphate/vitamin D analogs discontinued ≥1 week prior

4. Monitoring Commitment

  • Detailed plan for serum phosphorus monitoring
  • Baseline labs attached (phosphate, calcium, PTH, creatinine, 25(OH)D)
  • Provider agreement to adjust dosing based on phosphate levels

Documentation That Strengthens Your Case

From our advocates: We've seen the strongest approvals when families work with their endocrinologist to create a comprehensive "story" that connects genetic testing, failed conventional therapy, and current symptoms in a clear timeline. One approach that works well is organizing all prior treatments by date, dose, duration, and specific outcomes—this makes it easy for Humana's reviewers to see why Crysvita is medically necessary.

Avoid These Costly Mistakes

1. Incomplete Baseline Laboratory Documentation

The Problem: Submitting prior authorization without recent serum phosphorus levels or missing key labs like FGF23, calcium, or PTH.

The Fix: Attach lab reports (not just typed values) showing:

  • Serum phosphate below normal range
  • Calcium, PTH, creatinine/eGFR within 30-90 days
  • FGF23 if available (especially important without genetic confirmation)

2. Vague Step Therapy Documentation

The Problem: Writing "patient failed oral phosphate" without specifics.

The Fix: Document exact medications, doses, duration, and objective outcomes:

  • "Oral phosphate 1-2 g/day + calcitriol 0.25-0.5 mcg BID for 18 months (1/2022-7/2023)"
  • "Despite therapy, serum phosphate remained 1.8-2.1 mg/dL (normal 2.5-4.5 mg/dL)"
  • "Patient developed nephrocalcinosis on imaging 6/2023"

3. Missing Monitoring Plan

The Problem: No commitment to ongoing lab surveillance.

The Fix: Include explicit statement: "Provider agrees to monitor serum phosphorus every 4 weeks initially, then every 3 months long-term, with dose adjustments per FDA labeling."

4. Wrong Form or Submission Method

The Problem: Using generic prior authorization forms instead of Humana-specific documents.

The Fix: Use Humana's Medicare Part D Coverage Determination form and submit via fax (877-486-2621) or provider portal.

5. Concurrent Oral Phosphate Use

The Problem: Continuing oral phosphate or vitamin D analogs while requesting Crysvita.

The Fix: Document explicit discontinuation: "All oral phosphate and active vitamin D analogs discontinued [date], at least 1 week prior to proposed Crysvita initiation."

Quick Action Plan: 3 Steps to Take Today

Step 1: Verify Your Coverage and Gather Documents (Patient)

  • Log into MyHumana to confirm Crysvita's formulary status
  • Collect insurance card, recent lab results, and genetic testing reports
  • Request copies of prior treatment records from all providers who prescribed oral phosphate/vitamin D

Step 2: Schedule Strategic Provider Visit (Patient + Clinician)

  • Book appointment with endocrinologist familiar with XLH
  • Bring timeline of all previous treatments with dates, doses, and outcomes
  • Request comprehensive lab panel: phosphate, calcium, PTH, creatinine, 25(OH)D, FGF23

Step 3: Submit Complete Prior Authorization (Clinician)

  • Download Humana's current PA form
  • Complete every field including weight-based dosing rationale
  • Attach: specialist note, lab reports, genetic testing, step therapy documentation
  • Fax to 877-486-2621 with delivery confirmation

Expected Timeline: Standard decisions within 72 hours; expedited decisions within 24 hours if urgent clinical need documented.

Appeals Process for Florida Residents

If Humana denies your initial request, Florida residents have well-defined appeal rights:

Internal Appeal (Redetermination)

  • Deadline: 65 days from denial notice
  • Timeline: Humana must decide within 7 days for standard appeals
  • How to file: Use denial notice instructions or call member services
  • What to include: Address specific denial reasons with additional documentation

External Review (Florida)

  • When available: After exhausting internal appeals
  • Timeline: 4 months to request after final internal denial
  • Process: File through Florida Department of Financial Services
  • Cost: Free to consumers
  • Decision: Binding on Humana if overturned

Expedited Appeals

For urgent situations where 72-hour delays could harm your health:

  • Request expedited internal and external review simultaneously
  • Provide prescriber statement supporting urgency
  • External review decision within 72 hours

Florida Consumer Assistance: Call 1-877-693-5236 for help navigating appeals or file complaints online through the Division of Consumer Services.

Resources & Support

Official Humana Resources

Florida State Resources

Manufacturer Support

Coverage Appeals Assistance

For complex denials requiring targeted, evidence-backed appeals, Counterforce Health specializes in turning insurance denials into successful approvals by identifying specific denial reasons and crafting point-by-point rebuttals using each payer's own coverage criteria.

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage policies and appeal procedures may change. Always consult with your healthcare provider and insurance plan for the most current requirements and personalized guidance for your specific situation.

Sources & Further Reading:

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