Topic

Insurance Approval

A collection of 885 issues

How to Get Pomalyst (Pomalidomide) Covered by Humana in Michigan: Prior Authorization Guide & Appeal Templates

Answer Box: Getting Pomalyst (Pomalidomide) Covered by Humana in Michigan Fastest path to approval: Submit prior authorization with documented failure of both lenalidomide and a proteasome inhibitor, plus oncologist letter confirming medical necessity. If denied, file internal appeal within 65 days, then request Michigan DIFS external review within 127 days.

How to Get Carbaglu (Carglumic Acid) Covered by Blue Cross Blue Shield of North Carolina: Appeals Guide and State Protections

Answer Box: Getting Carbaglu Covered in North Carolina Carbaglu (carglumic acid) requires prior authorization from Blue Cross Blue Shield of North Carolina for confirmed NAGS deficiency. The fastest path to approval: 1. Submit complete PA request with genetic/biochemical confirmation of NAGS deficiency and elevated plasma ammonia levels 2. Include

How to Get Onivyde (Irinotecan Liposome) Covered by Humana in Washington: Prior Authorization, Appeals & Network Requirements

Answer Box: Getting Onivyde Covered by Humana in Washington Humana covers Onivyde (irinotecan liposome) in Washington, but requires prior authorization (PA) for all regimens. The NALIRIFOX combination (Onivyde + oxaliplatin + 5-FU + leucovorin) is FDA-approved for first-line metastatic pancreatic cancer as of February 2024. Fastest path to approval: 1. Submit PA request

How to Get Bavencio (Avelumab) Covered by UnitedHealthcare in New York: Prior Authorization, Appeals, and Cost Reduction Strategies

Answer Box: Getting Bavencio Covered by UnitedHealthcare in New York Bavencio (avelumab) requires prior authorization from UnitedHealthcare and is dispensed through specialty pharmacies only. In New York, if denied, you can file an external appeal with the Department of Financial Services within 4 months. First step today: Contact your oncologist

How Long Does It Take to Get Ilaris (Canakinumab) Approved by Aetna CVS Health in Texas? Complete Timeline Guide

Answer Box: Getting Ilaris (Canakinumab) Covered by Aetna CVS Health in Texas Standard approval timeline: 30-45 days for prior authorization, with over 95% of eligible requests processed within 24 hours. Expedited reviews for urgent cases must be completed within 72 hours under Texas law. Fastest path to approval: 1. Prescriber

How to Get Ferriprox (deferiprone) Covered by UnitedHealthcare in Virginia: Complete Appeals Guide

Answer Box: Getting Ferriprox Covered by UnitedHealthcare in Virginia UnitedHealthcare requires prior authorization for Ferriprox (deferiprone) with step therapy requirements. Patients must typically try deferasirox or deferoxamine first unless contraindicated. To get approval: 1) Document transfusional iron overload diagnosis with ICD-10 E83.111, 2) Show prior chelator failures or contraindications,

Do You Qualify for Photrexa Coverage by Blue Cross Blue Shield in Illinois? Decision Tree & Next Steps

Answer Box: Your Fast Track to Photrexa Coverage You likely qualify for Photrexa coverage if: You have progressive keratoconus or post-refractive corneal ectasia with documented progression (Kmax increase ≥1.0D or pachymetry decrease ≥10-20 microns over 6-12 months). First step today: Have your eye doctor submit prior authorization through BCBS

Coding That Helps Get Idelvion (albutrepenonacog alfa) Approved by UnitedHealthcare in California: ICD-10, J-Code, and NDC Guide

Answer Box: Getting Idelvion Covered by UnitedHealthcare in California Idelvion (albutrepenonacog alfa) requires prior authorization from UnitedHealthcare with specific coding: Use ICD-10 code D67 (hereditary factor IX deficiency), HCPCS J7202 (1 IU per billing unit), and the correct NDC for your vial strength. Submit clinical documentation showing hemophilia B diagnosis,

When Fabrazyme Isn't Approved by UnitedHealthcare in Virginia: Formulary Alternatives & Exception Paths

Answer Box: Getting Fabrazyme Coverage Through UnitedHealthcare in Virginia If UnitedHealthcare denies Fabrazyme (agalsidase beta) for Fabry disease, you'll likely need to try their preferred alternative Elfabrio first due to step therapy requirements. Document any clinical reasons why Elfabrio isn't suitable, then request a formulary exception

Do You Qualify for Cystadane Coverage by Humana in Texas? Decision Tree & Next Steps

Answer Box: If you have confirmed homocystinuria with elevated homocysteine (>50 µmol/L) and documented CBS, MTHFR, or cobalamin deficiency, you likely qualify for Cystadane coverage through Humana in Texas. The fastest path: have your doctor submit prior authorization with genetic testing results, plasma homocysteine levels, and vitamin B6/