By Counterforce Health Team in Natpara (parathyroid hormone) —

The Requirements Checklist to Get Natpara (Parathyroid Hormone) Covered by Humana in Michigan

Quick Answer: Getting Natpara covered by Humana in Michigan requires prior authorization through CenterWell Specialty Pharmacy, documented failure of calcium/vitamin D therapy, and specialist consultation. Submit requests via Availity Essentials or call 800-523-0023. If denied, you have 65 days to appeal and can request external review through Michigan DIFS within 127 days. Start by gathering your diagnosis codes (E20.0-E20.9), lab results showing persistent hypocalcemia, and documentation of failed conventional therapy.

Table of Contents

  1. Who Should Use This Guide
  2. Member & Plan Basics
  3. Clinical Criteria Requirements
  4. Coding and Billing Information
  5. Documentation Packet Essentials
  6. Submission Process
  7. Specialty Pharmacy Routing
  8. After Submission: What to Expect
  9. Common Denial Prevention Tips
  10. Appeals Process in Michigan
  11. Quick Reference Checklist

Who Should Use This Guide

This checklist is designed for Michigan patients with hypoparathyroidism and their healthcare providers seeking Humana coverage for Natpara (parathyroid hormone). You'll find this guide most helpful if you're dealing with:

  • New Natpara requests where conventional calcium and vitamin D therapy has failed
  • Prior authorization denials that need systematic appeals
  • Transfer situations where you're switching to Humana from another insurer
  • Documentation gaps that have led to coverage delays

Important Note: As of late 2024, Natpara has extremely limited availability due to manufacturer supply interruptions. Takeda discontinued global manufacturing, with U.S. Special Use Program shipments ceasing December 31, 2025. Most new start requests are being denied due to lack of commercial supply rather than medical necessity issues.

Member & Plan Basics

Coverage Requirements at a Glance

Requirement Details Where to Verify Source
Prior Authorization Required for all requests Humana PA Search Tool Humana PA Lists
Plan Type Medicare Advantage/Part D Member ID card Humana Coverage
Specialty Pharmacy CenterWell required Provider portal CenterWell Specialty
Age Requirement 18+ years Clinical documentation FDA labeling
Specialist Requirement Endocrinologist consultation Referral/consult notes Payer policies

Plan-Specific Considerations

Medicare Advantage members should note that Natpara falls under Part B coverage as a specialty biologic, not Part D. This affects your:

  • Deductible application (Part B vs. Part D deductible)
  • Appeals timeline (65 days for Medicare Advantage)
  • External review options (both Medicare and Michigan state processes available)

Clinical Criteria Requirements

Primary Indication Requirements

Your diagnosis must meet these specific criteria:

Confirmed Hypoparathyroidism:

  • Persistent serum calcium < 8.5 mg/dL on multiple occasions
  • Low or undetectable parathyroid hormone (PTH) levels
  • Appropriate ICD-10 diagnosis code (see coding section)
  • Normal kidney function to exclude secondary causes

Step Therapy Documentation

Humana requires documented failure of conventional therapy before approving Natpara:

Required Failed Therapies:

  1. High-dose calcium supplementation (≥1,000 mg/day above dietary intake)
  2. Active vitamin D therapy (calcitriol ≥0.25 mcg/day or equivalent)
  3. Minimum trial duration of 12 weeks at maximally tolerated doses
  4. Documented reasons for failure:
    • Persistent hypocalcemia despite therapy
    • Intolerable side effects (hypercalciuria, kidney stones)
    • Inability to achieve target calcium levels

Laboratory Thresholds

Your medical records must include:

Lab Value Required Range Timing Notes
Serum Calcium < 8.5 mg/dL Multiple recent values Persistent despite therapy
Serum PTH Below normal range At least 2 occasions, 21+ days apart Within last 12 months
Serum Phosphate Normal or elevated Recent Consistent with hypoparathyroidism
25-OH Vitamin D ≥ 20 ng/mL Within 6 months Must be sufficient
Serum Magnesium Normal range Recent Rule out hypomagnesemia

Coding and Billing Information

ICD-10 Diagnosis Codes

Select the most specific code for your situation:

Code Description When to Use
E20.0 Idiopathic hypoparathyroidism Unknown cause, primary deficiency
E20.1 Pseudohypoparathyroidism Genetic resistance to PTH
E20.810 Autosomal dominant hypocalcemia Genetically confirmed
E20.811 Secondary hypoparathyroidism Due to other conditions
E20.812 Autoimmune hypoparathyroidism Immune-mediated destruction
E89.2 Postprocedural hypoparathyroidism Following surgery (thyroid, parathyroid)

Billing Codes

HCPCS Code: J3590 ("Unclassified biologics") - Natpara doesn't have a specific J-code

NDC Information: Historical NDC 55513-880-XX (verify current availability due to supply issues)

Documentation Packet Essentials

Provider Note Elements

Your physician's documentation should include:

Clinical History:

  • Onset and duration of hypoparathyroidism
  • Etiology (surgical, autoimmune, genetic, idiopathic)
  • Previous hospitalizations for hypocalcemia
  • Current symptoms and functional impact

Treatment History:

  • Specific calcium and vitamin D preparations tried
  • Doses, duration, and patient response
  • Reasons for discontinuation or failure
  • Any adverse events or contraindications

Current Status:

  • Recent laboratory values with dates
  • Physical examination findings
  • Assessment of disease control
  • Treatment goals and monitoring plan

Medical Necessity Letter Components

A strong letter of medical necessity should address:

  1. Patient identification and confirmed diagnosis
  2. Failed conventional therapy with specific details
  3. Clinical rationale for Natpara therapy
  4. Treatment goals and expected outcomes
  5. Monitoring plan for safety and efficacy
  6. References to clinical guidelines or FDA labeling
Clinician Corner: Include specific lab values, dates, and doses in your letter. Generic statements like "failed standard therapy" aren't sufficient. Reference the FDA prescribing information for approved indications and dosing.

Required Attachments

Gather these documents before submitting:

  • Recent laboratory results (calcium, PTH, phosphate, vitamin D)
  • Clinic notes documenting failed therapies
  • Specialist consultation reports
  • Hospital records for hypocalcemia episodes (if applicable)
  • Current medication list with doses and duration

Submission Process

Fastest Path to Approval

  1. Verify coverage using Humana's PA Search Tool
  2. Gather documentation (see checklist above)
  3. Submit via Availity Essentials or call 800-523-0023
  4. Complete clinical questionnaire if prompted online
  5. Follow up within 5-7 business days for status
  6. Coordinate with CenterWell once approved
  7. Monitor approval timeline (typically 14-30 days)

Submission Methods

Online (Preferred):

Phone:

  • Provider services: 800-523-0023
  • Have patient information and clinical summary ready
  • Request confirmation number

Fax:

  • Confirm current fax number through provider portal
  • Include cover sheet with patient demographics
  • Follow up to confirm receipt

Specialty Pharmacy Routing

CenterWell Specialty Pharmacy Requirements

Humana requires Natpara to be dispensed through CenterWell Specialty Pharmacy, their preferred specialty vendor.

Transfer Process:

  1. Physician submits prescription to CenterWell (fax: 877-405-7940)
  2. CenterWell contacts patient for insurance verification
  3. Prior authorization confirmed before dispensing
  4. Shipment coordinated with patient preferences
  5. Clinical support provided for adherence and monitoring

Patient Support Services:

  • Financial assistance coordination
  • Clinical pharmacist consultation
  • Adherence monitoring and reminders
  • Cold-chain shipping and storage guidance

Contact Information:

  • Patient services: 855-506-1633
  • Provider services: 800-486-2668
  • Hours: Monday-Saturday, extended hours available

After Submission: What to Expect

Timeline and Status Tracking

Stage Expected Timeline How to Check Status
Initial Review 2-5 business days Availity portal or phone
Clinical Review 7-14 business days Provider portal updates
Final Determination 14-30 days total Written notification sent
Appeal (if needed) 30-60 days Member services tracking

What to Record

Keep detailed records of:

  • Confirmation numbers for all submissions
  • Representative names and call dates
  • Status updates and next steps
  • Required additional information requests
  • Approval details including quantity and duration limits

From Our Advocates: "We've seen faster approvals when providers include specific calcium levels and exact doses of failed therapies in their initial submission. One patient's approval was delayed three weeks because the initial request said 'high-dose calcium' instead of listing the actual 2,000 mg daily dose that failed to control symptoms."

Common Denial Prevention Tips

Five Pitfalls to Avoid

  1. Incomplete step therapy documentation
    • Fix: Include specific medications, doses, duration, and outcomes
    • Evidence needed: Pharmacy records, clinic notes, lab results
  2. Missing specialist consultation
    • Fix: Ensure endocrinologist involvement in care
    • Documentation: Consultation notes or co-management letters
  3. Inadequate lab documentation
    • Fix: Provide multiple calcium and PTH values over time
    • Timing: Results should span several months showing persistent abnormalities
  4. Generic medical necessity letters
    • Fix: Include patient-specific details and quantified treatment failures
    • References: Cite specific guideline recommendations
  5. Incorrect billing codes
    • Fix: Use J3590 for billing, verify NDC availability
    • Coordination: Work with specialty pharmacy on coding

Appeals Process in Michigan

Humana Internal Appeals

Timeline: 65 days from denial notification

How to Submit:

  • Online through member portal
  • Phone: Member services number on ID card
  • Mail to address on denial letter

Required Information:

  • Member ID and denial reference number
  • Clinical documentation supporting medical necessity
  • Provider letter addressing denial reasons

Michigan External Review

If Humana's internal appeal is unsuccessful, Michigan residents can request external review through the Department of Insurance and Financial Services (DIFS).

Key Details:

  • Timeline: 127 days from final internal denial
  • Cost: Free to patients
  • Decision time: 60 days standard, 72 hours expedited
  • Contact: 877-999-6442

How to File:

  1. Complete DIFS External Review Request form (verify current form online)
  2. Include final denial letter from Humana
  3. Attach clinical documentation
  4. Submit online, by email, fax, or mail

Expedited Reviews: Available when delay would seriously jeopardize patient health. Requires physician letter stating medical urgency.

Quick Reference Checklist

Before You Start - Gather These Items:

  • Insurance card with member ID
  • Complete diagnosis with ICD-10 code
  • Lab results: calcium, PTH, phosphate, vitamin D, magnesium
  • Documentation of failed calcium/vitamin D therapy
  • Specialist consultation notes
  • Current medication list with doses
  • Previous denial letters (if applicable)

Submission Checklist:

  • Prior authorization form completed
  • Medical necessity letter attached
  • Lab results included (multiple dates)
  • Step therapy documentation provided
  • Specialist involvement documented
  • Correct ICD-10 and billing codes used
  • CenterWell Specialty Pharmacy contacted
  • Confirmation number recorded

After Submission:

  • Status checked within one week
  • Additional information requests addressed promptly
  • Approval details reviewed (quantity, duration limits)
  • Specialty pharmacy coordination completed
  • Appeal timeline noted (if needed)

About Counterforce Health

Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into successful appeals by creating targeted, evidence-backed submissions. The platform analyzes denial letters and plan policies to draft point-by-point rebuttals that align with each payer's specific requirements, pulling the right clinical citations and operational details that payers expect to see.

Medical Disclaimer: This guide provides general information about insurance coverage processes and should not replace professional medical advice. Always consult with your healthcare provider about treatment decisions and work with your insurance plan directly for coverage determinations.

Sources & Further Reading

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