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

StrataGraft Coverage by Humana in Virginia: Prior Authorization Guide, Appeals, and Decision Tree

Answer Box: StrataGraft Coverage by Humana in Virginia

StrataGraft requires prior authorization under Humana Medicare Advantage plans in Virginia. For adults with deep partial-thickness thermal burns, approval typically takes 15 business days when properly documented. First step today: Have your burn center submit a PA request through Humana's provider portal using HCPCS code J7353, including wound measurements, clinical photos, and medical necessity justification. If denied, Virginia residents can appeal through Medicare's federal process (not Virginia's state external review), with 60 days to file the first-level appeal. Step therapy requirements began in 2025, so document any contraindications to alternative treatments.

Table of Contents

  1. How to Use This Decision Tree
  2. Eligibility Triage: Do You Qualify?
  3. If "Likely Eligible": Document Checklist
  4. If "Possibly Eligible": Additional Testing
  5. If "Not Yet": Alternatives and Exceptions
  6. If Denied: Virginia Appeal Path
  7. Coverage Requirements at a Glance
  8. Common Denial Reasons & Solutions
  9. FAQ

How to Use This Decision Tree

This guide helps Virginia residents navigate StrataGraft coverage through Humana Medicare Advantage plans. Start with the eligibility triage below to determine your approval likelihood, then follow the appropriate pathway.

Important: StrataGraft is billed under Medicare Part B (medical benefit), not Part D (pharmacy benefit). Claims submitted to pharmacy benefits will be rejected.

Eligibility Triage: Do You Qualify?

✅ Likely Eligible if you have:

  • Age: 18 years or older
  • Diagnosis: Deep partial-thickness thermal burns with intact dermal elements
  • Clinical indication: Surgical intervention (grafting) is medically necessary
  • Setting: Treatment at an accredited burn center or qualified wound care facility
  • Documentation: Complete wound measurements, clinical photos, and burn depth assessment

⚠️ Possibly Eligible if you have:

  • Burns of uncertain depth requiring additional assessment
  • Limited prior documentation of burn severity
  • Treatment at a facility without specialized burn accreditation
  • Missing wound measurements or photographic documentation

❌ Not Yet Eligible if you have:

  • Superficial or full-thickness burns (outside FDA indication)
  • Non-thermal wounds (pressure ulcers, diabetic wounds, etc.)
  • Age under 18 years
  • Requests for non-burn indications

If "Likely Eligible": Document Checklist

Required Clinical Documentation

For your burn center to submit:

  • Wound Assessment
    • Total body surface area (TBSA) calculation
    • Burn depth confirmation (deep partial-thickness)
    • Wound measurements in square centimeters
    • Clinical photographs with measurement scale
  • Medical Necessity Justification
    • Statement that surgical intervention is indicated
    • Rationale for StrataGraft over standard autograft
    • Documentation of any autograft limitations or contraindications
  • Prior Authorization Form
    • Submit via Humana provider portal using HCPCS code J7353
    • Include ICD-10 burn diagnosis codes (T21-T31 series)
    • Specify intended treatment area and unit calculation

Submission Timeline

  • Standard PA decision: 15 business days
  • Expedited review: 24 hours (for urgent cases with clinical justification)

If "Possibly Eligible": Additional Testing

Steps to Strengthen Your Case

  1. Obtain burn depth assessment from a qualified burn specialist
  2. Document wound measurements with standardized photography
  3. Gather treatment history showing why autograft alternatives are needed
  4. Consider facility transfer to an accredited burn center if current facility lacks expertise

Timeline for Reapplication

  • Allow 2-4 weeks for additional documentation
  • Resubmit PA request with complete clinical package
  • Consider expedited review if wound condition deteriorates

If "Not Yet": Alternatives and Exceptions

Alternative Coverage Options

For non-qualifying burns:

  • Integra Dermal Regeneration Template: Covered for deep burns requiring staged reconstruction
  • Standard autograft: Gold standard coverage for full-thickness burns
  • AlloDerm: May be covered as temporary scaffold in specific cases

Exception Request Process

If your case falls outside standard criteria, your physician can request a medical necessity exception by:

  1. Documenting unique clinical circumstances
  2. Providing peer-reviewed literature supporting off-label use
  3. Obtaining specialist consultation letters
  4. Submitting detailed treatment rationale

If Denied: Virginia Appeal Path

Critical: Virginia residents with Humana Medicare Advantage must use federal Medicare appeals, not Virginia's state external review process.

Level 1: Internal Appeal (Reconsideration)

  • Deadline: 60 days from denial notice
  • Timeline: Decision within 30 days (7 days for expedited)
  • How to file: Call 1-800-MEDICARE or submit through Humana member portal
  • Required: Original denial letter, additional clinical documentation

Level 2: Independent Review Entity (IRE)

  • Automatic: If Level 1 upheld, case goes to MAXIMUS Federal Services
  • Timeline: 30 days for standard, 72 hours for expedited
  • Focus: Independent medical review of clinical necessity

Level 3+: Administrative Law Judge

  • Requirement: Minimum dollar threshold ($180 in 2024)
  • Process: Formal hearing with medical evidence presentation

For assistance: Contact Virginia's State Health Insurance Assistance Program (SHIP) at 1-800-552-3402.

Coverage Requirements at a Glance

Requirement What It Means Source
Prior Authorization Required for all StrataGraft requests Humana PA List
Age Restriction Adults 18+ only (FDA indication) FDA Label
Diagnosis Codes ICD-10 T21-T31 (thermal burns) CMS Guidelines
Billing Code HCPCS J7353 per square centimeter Medicare Part B
Step Therapy May require trial of alternatives (2025+) Humana Step Therapy List
Site of Care Qualified burn center or wound facility Clinical Guidelines

Common Denial Reasons & Solutions

Denial Reason How to Overturn Required Documentation
"Not medically necessary" Provide burn depth assessment, photos, specialist consultation Clinical photos, wound measurements, burn specialist letter
"Experimental/investigational" Submit FDA approval documentation and clinical trial data FDA approval letter, peer-reviewed studies
"Step therapy not met" Document contraindications or failures of required alternatives Prior treatment records, allergy documentation, clinical notes
"Wrong billing code" Resubmit under Part B medical benefit with J7353 Corrected claim with proper HCPCS coding
"Insufficient documentation" Submit complete clinical package with measurements and photos Standardized wound photos, TBSA calculations, treatment plan

FAQ

How long does Humana prior authorization take for StrataGraft in Virginia? Standard PA decisions take up to 15 business days. Expedited reviews for urgent cases are completed within 24 hours when clinical urgency is documented.

What if StrataGraft isn't on Humana's formulary? StrataGraft is billed under Medicare Part B (medical benefit), not pharmacy formulary. It's covered when medically necessary for FDA-approved indications.

Can I request an expedited appeal in Virginia? Yes, expedited appeals are available through Medicare when delay could seriously jeopardize health. Your physician must certify medical urgency.

Does step therapy apply if I've tried treatments outside Virginia? Yes, documented treatment failures from any location count toward step therapy requirements. Ensure all prior treatments are properly documented.

What's the success rate for StrataGraft appeals? While specific Virginia data isn't available, Medicare appeals have higher success rates when supported by complete clinical documentation and specialist letters.

Who can help with my Humana appeal in Virginia? Contact Virginia SHIP at 1-800-552-3402 for free Medicare assistance, or call 1-800-MEDICARE for federal appeal guidance.

When Coverage Gets Complex

Navigating prior authorizations and appeals for advanced treatments like StrataGraft can be overwhelming, especially when dealing with burn injuries that require urgent care. Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals by analyzing denial letters, plan policies, and clinical notes to identify the specific denial basis and craft point-by-point rebuttals aligned with each plan's own rules.

The platform pulls the right evidence—FDA labeling, peer-reviewed studies, and specialty guidelines—and weaves them into appeals with required clinical facts like diagnosis codes, prior treatments, and dosing rationale. For complex cases like StrataGraft, having expert support can make the difference between a successful appeal and prolonged treatment delays.

Sources & Further Reading

Disclaimer: This information is for educational purposes and does not constitute medical or legal advice. Coverage policies vary by plan and may change. Always verify current requirements with your insurer and consult your healthcare provider for medical decisions. For personalized assistance with coverage appeals, consider consulting with specialists like Counterforce Health who can help navigate complex prior authorization requirements.

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