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

Myths vs. Facts: Getting StrataGraft Covered by Aetna (CVS Health) in Michigan - Prior Authorization Guide

Answer Box: StrataGraft Coverage by Aetna (CVS Health) in Michigan

Eligibility: Adults 18+ with deep partial-thickness thermal burns requiring surgical intervention when autograft isn't available or feasible. Fastest path: Submit prior authorization via Aetna provider portal using HCPCS code J7353 with complete wound documentation, burn depth assessment, and medical necessity justification. First step today: Have your burn surgeon gather wound measurements, clinical photos, and documentation that autograft is contraindicated or unavailable. Appeals in Michigan have 127 days for external review through DIFS if internal appeals fail.

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Why Myths About StrataGraft Coverage Persist

When you're dealing with severe burns, the last thing you need is confusion about insurance coverage. Yet myths about getting StrataGraft approved by Aetna (CVS Health) in Michigan spread faster than facts. These misconceptions often stem from the complexity of burn treatment billing—StrataGraft isn't a typical medication but a tissue-engineered product billed through the medical benefit, not pharmacy channels.

The stakes are high: StrataGraft can reduce or eliminate the need for painful autograft procedures, but only if you navigate Aetna's specific requirements correctly. Michigan patients face additional layers of state-specific appeal rights that many don't fully understand.

Counterforce Health specializes in turning insurance denials into successful appeals by identifying exactly what payers like Aetna require and crafting evidence-backed responses. Their platform helps patients and clinicians understand the real coverage criteria rather than relying on assumptions that lead to denials.

Let's separate fact from fiction so you can focus on healing, not fighting with insurance.

Common Myths vs. Facts

Myth 1: "If my burn surgeon prescribes StrataGraft, Aetna will automatically cover it"

Fact: Prior authorization is mandatory for StrataGraft regardless of who prescribes it. Even at accredited burn centers, coverage requires meeting specific clinical criteria: deep partial-thickness thermal burns where autograft isn't available or feasible due to the patient's condition, no burn wound infection, and complete wound excision with achieved hemostasis.

Myth 2: "StrataGraft is covered like any other prescription medication"

Fact: StrataGraft is billed as a facility procedure using HCPCS code J7353, not through pharmacy benefits. Claims submitted to CVS Caremark's pharmacy benefit will be automatically denied. It must be billed through Aetna's medical benefit during the surgical procedure.

Myth 3: "Age doesn't matter for StrataGraft coverage"

Fact: FDA approval is limited to adults 18 years and older. Aetna follows FDA indications strictly—pediatric burn patients cannot receive coverage for StrataGraft regardless of burn severity or medical necessity arguments.

Myth 4: "Any burn qualifies for StrataGraft coverage"

Fact: Only deep partial-thickness thermal burns qualify. Aetna's clinical policy specifically excludes superficial burns, chronic wounds, diabetic ulcers, and non-thermal injuries. The burn must have intact dermal elements requiring surgical intervention.

Myth 5: "If Aetna denies coverage, there's nothing I can do"

Fact: Michigan patients have robust appeal rights. You have 127 days to file an external review with the Michigan Department of Insurance and Financial Services (DIFS) after Aetna's final internal denial. DIFS decisions are binding and often overturn denials with proper documentation.

Myth 6: "Documentation from any doctor is sufficient for approval"

Fact: Aetna requires documentation specifically from the treating burn surgeon or wound specialist. The physician must provide wound measurements in square centimeters, clinical photographs with measurement scales, burn depth assessment, and detailed justification for why autograft isn't viable.

Myth 7: "Emergency room treatment automatically qualifies for coverage"

Fact: The procedure must occur at an accredited burn center or specialized wound care facility. Emergency departments typically provide initial stabilization, but StrataGraft application requires specialized surgical expertise and facility capabilities that Aetna verifies before approval.

Myth 8: "Expedited appeals aren't available for burn treatments"

Fact: Michigan offers 72-hour expedited external appeals when delays would seriously jeopardize health. For urgent burn treatments, your surgeon can request expedited review by providing a letter stating that treatment delay would harm the patient.

What Actually Influences Approval

Understanding Aetna's real decision-making process helps you submit winning prior authorization requests:

Clinical Criteria Checklist

  • Age verification: Patient must be 18+ years old
  • Burn classification: Deep partial-thickness thermal burns only
  • Surgical necessity: Documentation that autograft is unavailable or contraindicated
  • Wound status: No active infection present
  • Procedural readiness: Complete excision achieved with hemostasis

Documentation Requirements

Your burn surgeon must provide:

  • Wound measurements in square centimeters
  • Clinical photographs with measurement scales
  • ICD-10 burn codes (T21-T31 series)
  • Total body surface area (TBSA) calculations
  • Previous treatment attempts and outcomes
  • Medical history including contraindications to autograft

Facility and Provider Credentials

  • Treatment at accredited burn center or wound care facility
  • Board-certified burn surgeon or plastic surgeon
  • Facility must have appropriate surgical capabilities
  • Provider must be in Aetna's network (verify current status)
From our advocates: We've seen denials reversed simply by adding precise wound measurements and clinical photos that were missing from initial submissions. One Michigan patient's appeal succeeded after their burn center provided detailed TBSA calculations and documentation of why donor sites weren't adequate for autograft—information that was assumed to be obvious but wasn't explicitly stated in the original request.

Avoid These Critical Mistakes

1. Submitting to Wrong Benefit Channel

Mistake: Filing claims through CVS Caremark pharmacy benefit Fix: Always use medical benefit with HCPCS code J7353 during facility billing

2. Incomplete Wound Documentation

Mistake: Providing general burn assessment without specific measurements Fix: Include wound size in square centimeters, depth assessment, and clinical photos with measurement scales

3. Missing Medical Necessity Justification

Mistake: Assuming burn severity alone justifies coverage Fix: Explicitly document why autograft isn't available or feasible—insufficient donor sites, patient condition, surgical contraindications

4. Delayed Prior Authorization Submission

Mistake: Waiting until day of surgery to submit PA request Fix: Submit PA immediately after burn assessment, allowing 7-10 business days for review

5. Inadequate Appeals Documentation

Mistake: Simply restating original request in appeals Fix: Address specific denial reasons with additional clinical evidence, peer-reviewed literature, and detailed medical necessity arguments

Quick Action Plan: Three Steps to Take Today

Step 1: Verify Coverage and Gather Documentation (Patient + Surgeon)

  • Confirm your Aetna plan includes medical benefit coverage
  • Have your burn surgeon document wound measurements, photos, and burn depth
  • Collect all prior treatment records and autograft feasibility assessment
  • Timeline: Complete within 24-48 hours of burn assessment

Step 2: Submit Prior Authorization (Surgeon/Facility)

  • Use Aetna provider portal with HCPCS code J7353
  • Include complete clinical documentation package
  • Request expedited review if surgery is urgent (within 72 hours)
  • Timeline: Submit within 3-5 days of initial assessment

Step 3: Prepare for Potential Appeal (Patient + Surgeon)

  • Document all communication with Aetna
  • Gather additional supporting literature if needed
  • Identify backup funding sources (manufacturer programs, hospital financial assistance)
  • Timeline: Begin preparation immediately; appeals must be filed within 60 days of denial

Counterforce Health's platform can help streamline this process by automatically identifying which documentation Aetna requires and drafting appeals that address specific denial reasons with targeted evidence.

Michigan Appeals Process

If Aetna denies your StrataGraft prior authorization, Michigan law provides strong consumer protections:

Internal Appeal (Required First Step)

  • Deadline: 60 days from denial notice
  • Process: Submit through Aetna member portal or call customer service
  • Timeline: Standard decision within 30-45 days; expedited within 72 hours for urgent cases
  • Required documents: Denial letter, additional clinical evidence, medical necessity letter

External Review Through DIFS

Expedited Appeals for Urgent Burns

  • Eligibility: When treatment delay would seriously jeopardize health
  • Requirement: Physician letter confirming medical urgency
  • Timeline: 72-hour decision for both internal and external appeals
  • Contact: DIFS at 877-999-6442 for expedited processing

Coverage at a Glance

Requirement What It Means Where to Find It Source
Prior Authorization Mandatory before treatment Aetna provider portal Clinical Policy Bulletin
Age Limit Adults 18+ only FDA label FDA Approval Letter
Burn Type Deep partial-thickness thermal burns Medical assessment Aetna Coverage Criteria
Billing Code HCPCS J7353 (per sq cm) Facility billing department CMS Guidelines
Appeals Deadline 127 days for external review DIFS website Michigan DIFS

Resources and Support

Official Coverage Information

Patient Assistance

  • DIFS Consumer Assistance: 877-999-6442 (Monday-Friday, 8 AM-5 PM)
  • Aetna Member Services: Check your member ID card for plan-specific number
  • Mallinckrodt Patient Support: Contact through prescriber for access programs

Professional Support

For healthcare providers and patients dealing with complex coverage denials, Counterforce Health offers specialized expertise in turning insurance denials into successful appeals through evidence-backed, payer-specific strategies.

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 your insurer and consult healthcare professionals for medical decisions. For the most up-to-date Michigan insurance regulations, visit the Michigan Department of Insurance and Financial Services.

Sources & Further Reading

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