By Counterforce Health Team in Cresemba (isavuconazole) —

Work With Your Doctor to Get Cresemba (Isavuconazole) Approved by Humana in Michigan: Complete Provider Collaboration Guide

Answer Box: Getting Cresemba Approved by Humana in Michigan

To get Cresemba (isavuconazole) covered by Humana in Michigan, you'll need prior authorization with infectious disease specialist involvement and documented failure/intolerance of first-line antifungals like voriconazole. Your doctor must submit clinical evidence including culture results, imaging, and detailed justification. If denied, you have 65 days to appeal and can request external review through Michigan DIFS within 127 days. First step: Schedule an appointment with your prescriber to review your fungal infection diagnosis and gather required documentation.

Table of Contents

  1. Set Your Goal: Understanding What Approval Requires
  2. Prepare for Your Provider Visit
  3. Build Your Evidence Kit
  4. Structure the Medical Necessity Letter
  5. Support Your Doctor with Peer-to-Peer Review
  6. Document Everything After Your Visit
  7. Practice Respectful Persistence
  8. Humana Appeals Process in Michigan
  9. Common Denial Reasons & Solutions
  10. Cost-Saving Resources
  11. When to Escalate

Set Your Goal: Understanding What Approval Requires

Coverage at a Glance

Requirement What It Means Where to Find It Source
Prior Authorization Humana must approve before dispensing Humana PA Lists Humana Provider Portal
Specialist Involvement Infectious disease consultation required PA request form Humana PA Policy
Diagnosis Documentation Confirmed invasive aspergillosis/mucormycosis Culture/pathology reports Clinical guidelines
First-Line Failure Voriconazole intolerance/failure documented Treatment history FDA Cresemba Label
Appeals Deadline 65 days from denial notice Denial letter Humana Member Appeals

Your partnership with your healthcare provider is crucial because Humana requires comprehensive clinical documentation that only your medical team can provide. The goal isn't just to request Cresemba—it's to build an airtight case for medical necessity that addresses every criterion in Humana's policy.

Counterforce Health helps patients and clinicians navigate exactly this type of complex prior authorization by turning insurance denials into targeted, evidence-backed appeals. Their platform identifies denial reasons and drafts point-by-point rebuttals aligned to each plan's specific rules.

Prepare for Your Provider Visit

Checklist: What to Gather Before Your Appointment

  • Insurance card with Humana member ID
  • Complete list of antifungal medications tried (names, doses, duration, outcomes)
  • Documentation of side effects or treatment failures
  • Recent lab results (cultures, galactomannan, beta-D-glucan)
  • Imaging reports (CT, MRI showing fungal infection)
  • Previous denial letters or EOBs
  • Symptom timeline and functional impact notes

Key Questions to Discuss:

  1. Diagnosis confirmation: "What specific tests confirm my invasive aspergillosis or mucormycosis?"
  2. Treatment history: "Can you document why voriconazole or amphotericin B didn't work for me?"
  3. Medical necessity: "What makes Cresemba the best choice for my specific situation?"
  4. Timeline: "How urgent is starting this treatment?"
Tip: Bring a written timeline of your symptoms and treatments. This helps your doctor quickly understand your case and speeds up documentation.

Build Your Evidence Kit

Your doctor will need comprehensive evidence to support the PA request. Here's what should be included:

Required Clinical Documentation:

  • Definitive diagnosis with ICD-10 codes (B44.0-B44.7 for aspergillosis, B46.0-B46.9 for mucormycosis)
  • Culture/pathology results showing organism identification
  • Imaging studies demonstrating invasive disease
  • Infectious disease consultation notes
  • Prior antifungal therapy table with specific outcomes and adverse events

Supporting Laboratory Evidence:

  • Galactomannan levels (≥0.7 in serum, ≥1.0 in BAL for aspergillosis)
  • Beta-D-glucan results (noting these are negative in mucormycosis)
  • Tissue biopsy results when available
  • PCR testing if performed

Structure the Medical Necessity Letter

Clinician Corner: Medical Necessity Letter Template

Your doctor's letter should follow this structure:

  1. Patient demographics and diagnosis with specific ICD-10 codes
  2. Clinical presentation including symptoms and risk factors
  3. Diagnostic evidence (culture, pathology, imaging, lab markers)
  4. Prior therapy documentation with specific reasons for failure/intolerance
  5. Medical rationale for choosing Cresemba over alternatives
  6. Treatment plan including dosing and monitoring
  7. References to FDA labeling and clinical guidelines

Key elements to emphasize:

  • Voriconazole intolerance/failure with specific adverse events documented
  • Clinical urgency if disease is progressing
  • Specialist recommendation supporting Cresemba use
  • Alignment with IDSA guidelines for invasive fungal infections

Support Your Doctor with Peer-to-Peer Review

If your initial PA is denied, your doctor can request a peer-to-peer review with Humana's medical director.

How to Support This Process:

  1. Offer availability windows when your doctor can take the call
  2. Prepare a concise case summary highlighting key points:
    • Confirmed diagnosis with culture/pathology
    • Documented failure of first-line therapy
    • Clinical rationale for Cresemba specifically
    • Risks of treatment delay

Script for Your Doctor's Office: "We're requesting a peer-to-peer review for [patient name] regarding Cresemba prior authorization. The patient has confirmed invasive [aspergillosis/mucormycosis] with documented voriconazole intolerance. When can we schedule this discussion?"

Document Everything After Your Visit

What to Save:

  • Copy of PA request submitted to Humana
  • All supporting documentation sent
  • Confirmation numbers or submission receipts
  • Timeline for expected decision
  • Contact information for follow-up

Portal Communication Tips:

  • Use your patient portal to request copies of all submitted documents
  • Ask for notification when Humana responds
  • Request updates if you don't hear back within expected timeframes

Practice Respectful Persistence

Follow-Up Timeline:

  • Day 3-5: Check with your doctor's office on submission status
  • Day 10-14: Follow up on Humana's decision timeline
  • Day 21: If no response, escalate through your doctor's office
  • Day 30: Consider filing a complaint with Humana member services

Communication Scripts:

For your doctor's office: "Hi, I'm following up on my Cresemba prior authorization submitted [date]. Has Humana responded yet? Is there anything else they need from us?"

For Humana: "I'm calling about prior authorization request [number] for Cresemba submitted [date]. Can you provide a status update and expected decision timeline?"

From Our Advocates: We've seen cases where persistent, polite follow-up revealed missing documents that could have delayed approval for weeks. A simple check-in call often identifies and resolves issues quickly.

Humana Appeals Process in Michigan

Step-by-Step Appeals Timeline:

Level Who Files Timeline How to Submit Required Forms
Internal Appeal Patient or provider 65 days from denial Humana member portal or mail Coverage determination request
Expedited Appeal Patient with urgent need 72 hours decision Phone: 1-800-HUMANA (1-800-486-2621) Prescriber urgency statement
External Review Patient 127 days from final denial Michigan DIFS online form External review application

Michigan-Specific Rights: Michigan's Patient's Right to Independent Review Act gives you 127 days (rather than the federal 120-day standard) to file for external review with the Department of Insurance and Financial Services (DIFS). This extra week can be crucial for gathering additional evidence.

Expedited External Review: If your health would be in serious jeopardy by waiting, Michigan DIFS can issue a decision within 72 hours. Your doctor must provide a supporting letter stating that delay would harm you.

Common Denial Reasons & Solutions

Denial Reason How to Overturn Required Documentation
"Step therapy not completed" Document voriconazole failure/intolerance Detailed adverse event records, treatment timeline
"Not medically necessary" Strengthen clinical justification ID specialist consultation, culture results, imaging
"Experimental/investigational" Cite FDA approval and guidelines FDA label, IDSA recommendations
"Insufficient documentation" Provide complete clinical picture All lab results, pathology, prior therapy records

Cost-Saving Resources

Manufacturer Support:

  • Cresemba Access and Support program from Astellas Pharma
  • Patient assistance programs for eligible individuals
  • Copay cards for commercially insured patients

Foundation Resources:

  • Patient Access Network Foundation
  • HealthWell Foundation
  • State pharmaceutical assistance programs

When to Escalate

Contact Michigan DIFS if:

  • Humana violates appeal timelines
  • You're denied external review eligibility
  • There are procedural violations in the appeals process

Michigan Department of Insurance and Financial Services:

  • Phone: 877-999-6442
  • Online: michigan.gov/difs
  • External Review Request Form available online

For complex cases involving multiple denials or procedural issues, platforms like Counterforce Health can help identify specific denial reasons and draft targeted appeals that address each payer's unique requirements.

FAQ

How long does Humana prior authorization take in Michigan? Standard PA decisions are made within 72 hours of receiving complete documentation. Expedited requests are processed within 24 hours if urgent medical need is documented.

What if Cresemba is non-formulary on my plan? You can request a formulary exception with prescriber supporting statement. The same 72-hour timeline applies for standard requests.

Can I request an expedited appeal? Yes, if your prescriber certifies that waiting could seriously jeopardize your health. Humana must respond within 72 hours for expedited appeals.

Does step therapy apply if I failed voriconazole outside Michigan? Yes, documented treatment failures from any location count toward step therapy requirements, as long as you have proper medical records.

What happens if my external review is denied? External review decisions are binding, but you may have additional options through federal appeals processes or legal consultation for cases involving coverage violations.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Always consult with your healthcare provider and insurance company for specific guidance regarding your coverage and treatment options. Insurance policies and procedures may change; verify current requirements with official sources.

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