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

The Complete Requirements Checklist to Get StrataGraft Covered by Blue Cross Blue Shield in Illinois (2024 Forms and Appeals Guide)

Answer Box: Getting StrataGraft Covered by BCBS Illinois

StrataGraft requires prior authorization from Blue Cross Blue Shield of Illinois for deep partial-thickness thermal burns. Your fastest path to approval: (1) Verify your plan covers bioengineered skin substitutes under Illinois Public Act 103-0123, (2) Submit complete PA documentation including burn depth assessment and wound measurements via the BCBS provider portal, and (3) Include clinical photos with measurement scale and surgeon's medical necessity letter. Standard approval takes 15 business days; expedited review available for urgent cases within 24 hours.

Table of Contents

  1. Who Should Use This Checklist
  2. Member & Plan Basics
  3. Clinical Criteria Requirements
  4. Coding and Documentation Requirements
  5. Required Documentation Packet
  6. Submission Process
  7. After Submission: What to Expect
  8. Common Denial Reasons & How to Avoid Them
  9. Appeals Process for Illinois
  10. Printable Checklist

Who Should Use This Checklist

This guide is designed for Illinois patients with deep partial-thickness thermal burns requiring StrataGraft, along with their burn surgeons, wound care specialists, and care coordinators. You'll need this checklist if:

  • Your burn surgeon has recommended StrataGraft for wound coverage
  • You have Blue Cross Blue Shield of Illinois coverage (including HCSC plans)
  • Your burns involve >10% total body surface area or critical areas (face, hands, feet, joints)
  • Conservative treatments haven't achieved adequate healing within 10-14 days

Expected outcome: With complete documentation, approval rates for medically appropriate StrataGraft requests are generally favorable, particularly when Illinois' reconstructive tissue graft mandate applies.

Member & Plan Basics

Coverage Verification Steps

Before starting the prior authorization process:

  1. Confirm active BCBS Illinois coverage - Check your member ID card and verify benefits are current
  2. Identify your plan type - Commercial, Medicare Advantage, or Medicaid managed care plans have different requirements
  3. Review your medical benefit structure - StrataGraft is billed under medical benefits (HCPCS J7353), not pharmacy benefits
  4. Check deductible status - High-deductible plans may require meeting your annual deductible first
Note: StrataGraft bypasses typical specialty pharmacy pathways. The hospital or burn center handles billing directly under your medical benefit coverage.

Illinois-Specific Coverage Protections

Under Illinois Public Act 103-0123, private insurers including BCBS must cover medically necessary reconstructive tissue grafts. This mandate strengthens coverage for StrataGraft when used for appropriate burn indications.

Clinical Criteria Requirements

Medical Necessity Standards

StrataGraft is covered when ALL of these criteria are met:

Requirement Clinical Documentation Needed
Burn Depth Deep partial-thickness involvement confirmed by burn specialist
Burn Size Precise measurements in square centimeters with photographic evidence
Healing Failure Lack of progressive epithelialization over 10-14 days of conservative treatment
Surgical Indication Burn surgeon's assessment that autografting is clinically indicated
Anatomical Risk Burns involving critical areas or >10% TBSA requiring specialized coverage

FDA-Approved Indications

StrataGraft is FDA-approved specifically for deep partial-thickness thermal burns in adults when autografting is clinically indicated. Off-label uses (chronic wounds, non-burn injuries) typically face coverage challenges and require additional justification.

Step Therapy Requirements

Most BCBS Illinois plans do not require step therapy for StrataGraft when used for appropriate burn indications. However, documentation must show:

  • Conservative wound care attempted (debridement, topical agents, dressings)
  • Failure to achieve adequate healing within expected timeframe
  • Clinical rationale for advanced bioengineered skin substitute

Coding and Documentation Requirements

Essential Coding Information

Primary Billing Code:

  • HCPCS J7353 - StrataGraft, per 100 cm² construct
  • Unit calculation: Divide total wound area by 100 (e.g., 250 cm² = 3 units)

Required ICD-10 Codes:

  • Burn location codes: T20-T25 series (head/neck, trunk, limbs)
  • Burn extent codes: T31-T32 series (percentage of body surface)
  • External cause codes: Specify thermal injury mechanism

Supporting CPT Codes:

  • Surgical debridement and preparation codes
  • Burn excision codes (if applicable)
  • Anesthesia codes for operative procedures

Documentation Requirements

Wound Assessment Documentation:

  1. Total body surface area (TBSA) calculation using Rule of Nines or Lund-Browder chart
  2. Precise wound measurements in square centimeters
  3. Burn depth assessment with clinical characteristics (color, blanching, sensation)
  4. Clinical photographs with measurement scale clearly visible
  5. Serial wound assessments showing lack of healing progression

Required Documentation Packet

Core Documents for Prior Authorization

1. Provider Medical Necessity Letter Must Include:

  • Patient demographics and insurance information
  • Detailed burn history (mechanism, timing, initial treatment)
  • Current wound assessment with measurements and photos
  • Prior treatments attempted and outcomes
  • Clinical rationale for StrataGraft over alternatives
  • Expected treatment goals and monitoring plan

2. Clinical Records Required:

  • Initial burn center evaluation notes
  • Serial wound assessment notes (minimum 2 weeks)
  • Surgical consultation notes
  • Laboratory results (if infection suspected)
  • Imaging studies (if applicable)

3. Supporting Documentation:

  • Burn center referral letter (if applicable)
  • Photographs with measurement scale
  • Wound measurement worksheets
  • Previous treatment failure documentation

Medical Necessity Letter Template Elements

Your burn surgeon's letter should address these specific points:

Clinical Problem: "Patient presents with [X]% TBSA deep partial-thickness thermal burns involving [anatomical locations] sustained on [date]. Despite [duration] of conservative management including [specific treatments], wounds demonstrate [lack of healing indicators]."
Medical Necessity: "StrataGraft is medically necessary due to [specific clinical factors: extensive burn size, critical anatomical location, limited donor sites, patient comorbidities]. Conservative treatments have failed to achieve adequate healing, and delay in definitive coverage increases risk of [infection, hypertrophic scarring, functional impairment]."
Treatment Plan: "StrataGraft will be applied to [specific wound areas totaling X cm²] following surgical debridement. Expected outcomes include [wound closure timeline, functional preservation, reduced scarring risk]."

Submission Process

Step-by-Step Submission Guide

1. Gather Complete Documentation (1-2 days)

  • Compile all required documents listed above
  • Verify wound measurements and photo quality
  • Obtain surgeon's medical necessity letter

2. Complete BCBS Prior Authorization Form (Same day)

  • Use current BCBS Illinois PA form (verify version on provider portal)
  • Include precise HCPCS J7353 coding with correct units
  • Attach all supporting documentation

3. Submit via Provider Portal (Same day)

  • Log into BCBS Illinois provider portal
  • Upload complete PA request with all attachments
  • Record confirmation number and submission date

4. Verify Receipt (1-2 business days)

  • Confirm BCBS received complete submission
  • Note any requests for additional information
  • Schedule follow-up status checks

Submission Mechanics

Portal vs. Fax Submission:

  • Preferred: BCBS Illinois provider portal for faster processing
  • Alternative: Fax to prior authorization department (verify current fax number)
  • Not recommended: Mail submission due to processing delays

Required Fields That Commonly Cause Rejections:

  • Incomplete patient demographics or insurance information
  • Missing or incorrect HCPCS coding
  • Inadequate wound measurements or missing photos
  • Unsigned medical necessity letters
  • Missing burn center consultation notes

After Submission: What to Expect

Timeline and Status Tracking

Standard Review Process:

  • Initial review: 3-5 business days
  • Clinical review: 10-15 business days total
  • Decision notification: Via provider portal and fax

Expedited Review Available:

  • Criteria: Urgent medical need, ongoing hospitalization
  • Timeline: 24-48 hours
  • Request method: Mark "urgent" on PA form with clinical justification

What to Record

  • PA confirmation number
  • Submission date and method
  • BCBS case manager contact (if assigned)
  • Status check schedule (every 3-5 business days)
  • Any additional information requests

Common Denial Reasons & How to Avoid Them

Denial Reason Prevention Strategy
"Insufficient wound documentation" Include detailed measurements, photos with scale, and serial assessments
"Alternative treatments not attempted" Document specific conservative treatments tried and duration/outcomes
"Non-FDA approved indication" Confirm deep partial-thickness thermal burn diagnosis in documentation
"Incorrect billing pathway" Verify medical benefit billing with HCPCS J7353, not pharmacy codes
"Missing surgical justification" Include burn surgeon's detailed rationale for StrataGraft vs. autograft

From Our Advocates

"We've seen the strongest approvals when burn centers submit comprehensive photo documentation showing wound progression over 2-3 weeks, paired with detailed surgeon letters explaining why StrataGraft offers advantages over traditional autografting for the specific patient. The key is demonstrating both medical necessity and appropriate indication within FDA labeling."

Appeals Process for Illinois

Internal Appeals Process

Level 1 - Peer-to-Peer Review:

  • Timeline: Request within 30 days of denial
  • Process: Burn surgeon discusses case directly with BCBS medical director
  • Preparation: Have clinical notes, photos, and guidelines references ready

Level 2 - Formal Internal Appeal:

  • Timeline: 15 business days for standard, 24 hours for expedited
  • Submission: Written appeal with additional clinical evidence
  • Decision: Final internal determination from BCBS

Illinois External Review Process

If internal appeals are unsuccessful, Illinois law provides binding external review:

Filing Requirements:

Review Timeline:

  • Standard: 45 days maximum from submission
  • Expedited: 72 hours for urgent cases
  • Decision: Legally binding on BCBS Illinois

Support Resources:

  • Illinois Department of Insurance: (877) 527-9431
  • Attorney General Health Care Helpline: (877) 305-5145

Printable Checklist

Pre-Submission Requirements ✓

Patient Information:

  • Active BCBS Illinois coverage verified
  • Medical benefit deductible status confirmed
  • Patient demographics and insurance ID collected

Clinical Documentation:

  • Burn depth confirmed as deep partial-thickness
  • TBSA calculated and documented
  • Wound measurements in square centimeters recorded
  • Clinical photos with measurement scale obtained
  • Conservative treatment failure documented (10-14 days minimum)

Provider Documentation:

  • Burn surgeon medical necessity letter completed
  • Serial wound assessment notes (minimum 2 weeks)
  • Surgical consultation notes included
  • ICD-10 and HCPCS J7353 coding verified

Submission Process:

  • Current BCBS PA form completed
  • All attachments uploaded to provider portal
  • Confirmation number recorded
  • Status check schedule established

Post-Submission Tracking ✓

  • Initial receipt confirmed (1-2 days)
  • Status checked every 3-5 business days
  • Additional information requests addressed promptly
  • Decision received and documented
  • If denied, appeal timeline noted (30 days for peer-to-peer)

Need help navigating the StrataGraft approval process? Counterforce Health specializes in turning insurance denials into successful appeals by analyzing denial letters, identifying specific coverage criteria, and drafting evidence-backed rebuttals. Our platform helps patients, clinicians, and specialty pharmacies get prescription drugs and medical treatments approved by creating targeted appeals that address each payer's unique requirements and procedural standards.

For additional support with complex cases or appeals, Counterforce Health provides comprehensive coverage advocacy services designed to improve approval rates and reduce administrative burden for both patients and healthcare providers.

Sources & Further Reading

Disclaimer: This guide provides general information about insurance coverage processes and should not be considered medical or legal advice. Coverage decisions vary by individual plan and clinical circumstances. Always consult with your healthcare provider and insurance company for specific guidance regarding your situation. For complex appeals or coverage disputes, consider consulting with a healthcare advocate or attorney familiar with Illinois insurance law.

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