By Counterforce Health Team in Poteligeo (mogamulizumab-kpkc) —

The Complete Checklist to Get Poteligeo (mogamulizumab-kpkc) Covered by Humana in Georgia: Forms, Appeals, and Medical Necessity Guide

Quick Answer: Your Path to Coverage

Getting Poteligeo (mogamulizumab-kpkc) covered by Humana in Georgia requires prior authorization for all Medicare Advantage and Part D plans. You'll need confirmed CTCL diagnosis (mycosis fungoides or Sézary syndrome), documented failure of ≥1 prior systemic therapy, and submission through Humana's provider portal. If denied, Georgia residents have 60 days to file an external review through the Georgia Department of Insurance (1-800-656-2298). Start today by gathering your pathology report, treatment history, and staging documentation.

Table of Contents

  1. Who Should Use This Guide
  2. Member & Plan Basics
  3. Clinical Criteria Checklist
  4. Coding & Billing Requirements
  5. Documentation Packet
  6. Submission Process
  7. Specialty Pharmacy Coordination
  8. After Submission: Tracking & Follow-up
  9. Common Denial Reasons & Fixes
  10. Appeals Process in Georgia
  11. Printable Checklist

Who Should Use This Guide

This comprehensive checklist is designed for Georgia residents with Humana coverage (Medicare Advantage, Part D, or commercial plans) seeking approval for Poteligeo (mogamulizumab-kpkc) for cutaneous T-cell lymphoma (CTCL).

You're in the right place if:

  • You have confirmed mycosis fungoides or Sézary syndrome
  • You've tried at least one prior systemic therapy that failed or caused intolerance
  • Your oncologist or dermatologist has recommended Poteligeo
  • You've received a denial or want to avoid one

Expected outcome: Following this checklist typically results in approval within 7-30 days for standard requests, or 72 hours for expedited cases when properly documented.

Member & Plan Basics

Verify Active Coverage

Before starting any prior authorization process:

  • Check your Humana ID card for plan type (Medicare Advantage HMO/PPO, Part D, or commercial)
  • Confirm active enrollment through Humana's member portal
  • Review your formulary for Poteligeo's tier status and restrictions

Plan-Specific Requirements

Plan Type PA Required? Formulary Status Key Contact
Medicare Advantage Yes Non-formulary/Restricted Member Services (on ID card)
Part D Yes Tier 5 Specialty 1-866-488-5995 (Clinical Pharmacy)
Commercial Varies by employer Check plan documents Group benefits contact
Note: Humana's 2024 Medicare Advantage and Part D plans list Poteligeo on their preauthorization list, requiring medical necessity documentation regardless of formulary tier.

Clinical Criteria Checklist

FDA-Approved Indication Requirements

All of the following must be documented:

✅ Patient Age: Adult (≥18 years)

✅ Confirmed Diagnosis: Biopsy-proven cutaneous T-cell lymphoma, specifically:

  • Mycosis fungoides (ICD-10: C84.0-series), OR
  • Sézary syndrome (ICD-10: C84.1-series)

✅ Disease Status: Relapsed or refractory disease with objective evidence

✅ Prior Systemic Therapy: At least one prior systemic treatment with documented:

  • Drug name, dose, duration
  • Best response achieved
  • Reason for discontinuation (progression, intolerance, contraindication)

✅ TNMB Staging: Complete staging per ISCL/EORTC criteria

✅ Prescriber Qualification: Board-certified oncologist or dermatologist

Step Therapy Documentation

Common systemic therapies that satisfy the "prior treatment" requirement:

  • Bexarotene (Targretin)
  • Interferon-α
  • Methotrexate
  • HDAC inhibitors (vorinostat, romidepsin)
  • Brentuximab vedotin (for CD30+ disease)
  • Photopheresis
  • Systemic chemotherapy
Tip: If Humana requires specific step therapy (e.g., brentuximab first), you can request an exception by documenting contraindications like pre-existing neuropathy or prior severe reactions.

Coding & Billing Requirements

Primary Codes

Code Type Code Description Units
HCPCS J9204 Injection, mogamulizumab-kpkc, 1 mg Per mg administered
ICD-10 C84.0- Mycosis fungoides Site-specific
ICD-10 C84.1- Sézary syndrome Site-specific
NDC 42747-0761-01 20 mg/5 mL vial Per vial

Administration Codes

  • IV infusion: CPT 96413 (first hour), 96415 (additional 15 minutes)
  • Site of care: Hospital outpatient, oncology clinic, or qualified infusion center
  • Revenue codes: 0331 (nonchemotherapy drugs) or 0335 (chemotherapy)

Documentation Packet

Required Clinical Documents

1. Pathology Report

  • Tissue biopsy with immunohistochemistry
  • Confirmation of CTCL subtype (MF or SS)
  • Flow cytometry if applicable

2. Staging Documentation

  • Complete TNMB staging with supporting notes
  • Imaging reports (CT, PET, or MRI if visceral involvement)
  • Blood work showing Sézary cells if SS

3. Treatment History Summary Create a table format:

Drug Dates Dose/Schedule Best Response Reason for Discontinuation
[Prior therapy 1] MM/YY-MM/YY [Details] [CR/PR/SD/PD] [Progression/toxicity/etc.]

4. Current Clinical Status

  • Recent clinic notes (within 30 days)
  • Performance status (ECOG/Karnofsky)
  • Current symptoms and disease burden
  • Laboratory results (CBC, CMP)

Medical Necessity Letter Template

From our advocates: A well-structured medical necessity letter that directly addresses Humana's coverage criteria and includes specific treatment failure details typically reduces approval time by 50% compared to generic requests. Focus on documenting why alternatives are inappropriate rather than just stating they failed.

Key elements to include:

  1. Patient identification and confirmed CTCL diagnosis
  2. Prior systemic therapy failures with specific details
  3. Current disease status and progression evidence
  4. Medical rationale for Poteligeo specifically
  5. Treatment plan including dosing and monitoring
  6. Risk of delay if treatment is not approved

Download Kyowa Kirin's medical necessity letter template and customize with your patient's specific details.

Submission Process

Humana Prior Authorization Pathways

For Medicare Advantage/Part D:

  • Online: Humana provider portal
  • Phone: 1-866-488-5995 (Clinical Pharmacy)
  • Fax: 877-486-2621 (Part D coverage determinations)

Required Forms:

  • Humana Prior Authorization Request Form
  • Medicare Prescription Drug Coverage Determination Form (if Part D)

Submission Checklist

Before hitting "submit," verify:

✅ Complete PA form with all required fields ✅ Medical necessity letter attached ✅ Pathology report included ✅ Treatment history table provided ✅ Current staging documentation attached ✅ Prescriber NPI and credentials listed ✅ Correct member ID and plan details entered

Timeline Expectations

Request Type Standard Decision Expedited Decision
Part B (Medical) 14-30 days 72 hours
Part D (Pharmacy) 7 days 24 hours
Commercial Varies by plan 72 hours

Specialty Pharmacy Coordination

Preferred Network Pharmacies

Humana typically routes Poteligeo through:

  • CenterWell Specialty Pharmacy (primary)
  • Optum Specialty Pharmacy
  • Onco360 Oncology Pharmacy
  • PANTHERx Specialty Pharmacy

Coordination Steps

  1. Confirm specialty pharmacy assignment once PA is approved
  2. Provide site of care details (infusion center address, contact)
  3. Verify cold-chain shipping arrangements
  4. Document receipt and storage at infusion site
Note: Poteligeo requires refrigerated storage (2-8°C) and must be administered within specific timeframes after preparation.

After Submission: Tracking & Follow-up

Status Monitoring

  • Record confirmation number from submission
  • Check status via provider portal every 2-3 business days
  • Follow up by phone if approaching decision deadline
  • Document all communications with date, time, and representative name

What to Track

Item Information to Record
Submission date MM/DD/YYYY
Confirmation number [PA reference #]
Decision deadline MM/DD/YYYY
Status checks Date, outcome, next steps
Additional requests Documents, peer-to-peer, etc.

Common Denial Reasons & Fixes

Denial Reason How to Fix Required Documentation
Incomplete diagnosis Submit complete pathology report Tissue biopsy with immunohistochemistry confirming MF/SS
Insufficient prior therapy Provide detailed treatment timeline Table with drug names, dates, outcomes, failure reasons
Missing staging Submit TNMB staging documentation Clinic notes with complete staging per ISCL/EORTC
Step therapy not met Request exception with medical justification Letter explaining contraindications to required steps
Site of care concerns Confirm qualified infusion facility Facility accreditation, emergency protocols documentation

Peer-to-Peer Review Request

If facing a complex denial, request a peer-to-peer review:

  • Contact: Humana Clinical Pharmacy at 1-866-488-5995
  • Prepare: Clinical summary, treatment rationale, guideline references
  • Timeline: Usually scheduled within 72 hours of request

Appeals Process in Georgia

Internal Humana Appeals

Timeline to file: 60-65 days from denial date Decision timeframe:

  • Standard: 30 days (Part B), 7 days (Part D)
  • Expedited: 72 hours

Required documents:

  • Original denial letter
  • Updated medical necessity letter
  • Any new clinical information
  • Prescriber attestation of urgency (if expedited)

Georgia External Review

If Humana's internal appeal is denied, Georgia residents have additional rights:

Timeline to file: 60 days from final internal denial Contact: Georgia Department of Insurance Consumer Services Phone: 1-800-656-2298 Cost: Free to consumer Decision timeline: 30 business days (standard), 72 hours (expedited)

Important: The 60-day deadline for Georgia external review is strictly enforced. Mark your calendar immediately upon receiving Humana's final denial.

External review is binding - if the independent reviewer overturns Humana's denial, they must cover Poteligeo according to the decision.

When to Request Expedited Review

Your doctor should request expedited review if delay would:

  • Seriously jeopardize your health
  • Compromise your ability to regain maximum function
  • Risk disease progression requiring hospitalization

Printable Checklist

Pre-Submission Checklist

Patient Information:

  • Humana member ID and plan type verified
  • Active enrollment confirmed
  • Previous authorizations reviewed

Clinical Documentation:

  • Pathology report confirming MF or SS
  • Complete TNMB staging documented
  • Prior systemic therapy table completed
  • Current clinic notes (within 30 days)
  • Recent laboratory results included

Submission Package:

  • PA form completed with all required fields
  • Medical necessity letter attached
  • All supporting documents included
  • Prescriber credentials and NPI listed
  • Site of care information provided

Post-Submission:

  • Confirmation number recorded
  • Decision deadline noted on calendar
  • Follow-up schedule established
  • Contact information for appeals saved

Need additional support navigating insurance coverage? Counterforce Health specializes in turning insurance denials into successful appeals through evidence-based advocacy. Our platform analyzes denial letters and creates targeted, policy-specific appeals that align with each payer's requirements, helping patients and providers secure coverage for critical medications like Poteligeo.

Frequently Asked Questions

Q: How long does Humana prior authorization take for Poteligeo in Georgia? A: Standard decisions take 7-30 days depending on whether it's billed under Part B or Part D. Expedited reviews are completed within 24-72 hours when medical urgency is documented.

Q: What if Poteligeo is non-formulary on my plan? A: You can request a formulary exception along with your PA. Provide clinical justification for why formulary alternatives are inappropriate for your specific case.

Q: Can I appeal if my oncologist isn't in Humana's network? A: Yes, you can request a network adequacy exception if no in-network specialists in Georgia have appropriate CTCL expertise. Document the lack of qualified providers in your area.

Q: Does step therapy apply if I tried treatments in another state? A: Yes, prior therapy from any qualified provider counts toward step therapy requirements. Ensure you have complete documentation of out-of-state treatments.

Q: What happens if I miss the appeal deadline? A: Contact Georgia DOI Consumer Services immediately at 1-800-656-2298. In rare cases, they may accept late filings for good cause, but this isn't guaranteed.

Q: Is there financial assistance available for Poteligeo? A: Yes, Kyowa Kirin Cares offers copay assistance and patient support programs. Eligibility varies by insurance type and income.

This guide is for informational purposes only and does not constitute medical advice. Always consult with your healthcare provider and insurance plan for the most current coverage requirements. For additional help with insurance appeals in Georgia, contact the Georgia Department of Insurance Consumer Services at 1-800-656-2298.

Sources & Further Reading

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