By Counterforce Health Team in Kesimpta (ofatumumab) —

Work With Your Doctor to Get Kesimpta (Ofatumumab) Approved by Humana in New York: Complete Guide

Answer Box: Your Path to Kesimpta Approval

Kesimpta (ofatumumab) requires prior authorization from Humana for multiple sclerosis treatment. Success depends on strong provider partnership: your doctor must document relapsing MS diagnosis, prior therapy failures, and medical necessity. Start today by scheduling a visit to review your MS history and gather supporting records. If denied, New York residents have 4 months to file an external appeal through the NY Department of Financial Services. Key requirements: hepatitis B screening, vaccination updates, and step therapy documentation.

Table of Contents

  1. Set Your Goal: Understanding Approval Requirements
  2. Visit Preparation: Building Your Case
  3. Evidence Kit: What Your Doctor Needs
  4. Medical Necessity Letter Structure
  5. Peer-to-Peer Support Strategy
  6. After-Visit Documentation
  7. Respectful Persistence and Follow-Up
  8. Appeals Process in New York
  9. FAQ: Common Questions

Set Your Goal: Understanding Approval Requirements

Getting Kesimpta covered by Humana requires meeting specific medical criteria and following their prior authorization process. Here's what approval typically requires:

Coverage at a Glance

Requirement What It Means Where to Find It Source
Prior Authorization Humana must approve before dispensing Provider portal or fax 877-486-2621 Humana PA
Relapsing MS Diagnosis CIS, RRMS, or active SPMS with ICD-10 codes Your medical records FDA Label
Step Therapy May require trying preferred DMTs first Plan formulary (verify with plan) Plan-specific
HBV Screening Required before treatment Lab results (HBsAg, anti-HBc) FDA Label
Vaccination Updates Complete 2-4 weeks before starting Immunization records Kesimpta HCP

Your partnership strategy: You provide the clinical history and symptom details; your doctor translates this into medical language that meets Humana's criteria.

Visit Preparation: Building Your Case

Before your appointment, organize your MS journey into a clear narrative that supports medical necessity.

Symptom Timeline Checklist

  • Relapse history: Dates, symptoms, recovery time for each episode
  • MRI changes: New or enlarging lesions, gadolinium enhancement
  • Functional impact: Work limitations, mobility changes, cognitive effects
  • Current symptoms: Fatigue, weakness, sensory changes, walking difficulties

Treatment History Documentation

Create a comprehensive list of all MS therapies you've tried:

For each medication, note:

  • Exact name and dosing
  • Start and stop dates
  • Reason for discontinuation (ineffective, side effects, intolerance)
  • Specific adverse effects experienced
  • Any hospitalizations or complications
Tip: If you've tried multiple therapies, this strengthens your case for Kesimpta as a medically necessary next step.

Functional Impact Notes

Document how MS affects your daily life:

  • Work productivity and attendance
  • Driving ability and independence
  • Exercise tolerance and mobility
  • Cognitive function and memory
  • Social activities and relationships

Evidence Kit: What Your Doctor Needs

Your provider needs specific documentation to craft a compelling prior authorization request.

Essential Clinical Records

  • Recent MRI reports (within 6-12 months)
  • Laboratory results including hepatitis B screening
  • Vaccination records to confirm updates are complete
  • Prior therapy documentation from previous providers
  • Relapse documentation including emergency visits or steroid treatments

Published Guidelines Support

Your doctor should reference authoritative sources in the medical necessity letter:

  • FDA-approved indications for relapsing MS
  • American Academy of Neurology MS guidelines
  • National MS Society treatment recommendations

Medication History Summary

Help your provider create a chronological list:

  1. First-line therapies tried (interferons, glatiramer acetate)
  2. Oral agents attempted (fingolimod, dimethyl fumarate, etc.)
  3. Reasons for discontinuation with specific details
  4. Current disease activity despite prior treatments

Medical Necessity Letter Structure

A strong letter of medical necessity follows a specific format that addresses Humana's approval criteria.

Key Components Your Doctor Should Include

1. Patient Identification

  • Full name, date of birth, Humana member ID
  • Diagnosis with ICD-10 codes (G35 for MS)
  • Prescribing physician credentials

2. Clinical Rationale

  • Confirmed relapsing MS phenotype (CIS, RRMS, or active SPMS)
  • Evidence of ongoing disease activity
  • Inadequate response to or intolerance of preferred agents

3. Safety Documentation

  • Hepatitis B screening results (required per FDA labeling)
  • Vaccination status and updates completed
  • Assessment of infection risk

4. Treatment Goals

  • Reduce relapse frequency and severity
  • Prevent disability progression
  • Improve quality of life and function

5. Supporting References

  • FDA approval for relapsing MS
  • Clinical trial data demonstrating efficacy
  • Published treatment guidelines
Clinician Corner: The Kesimpta Authorization Kit provides sample letter templates on pages 17-20.

Peer-to-Peer Support Strategy

If Humana requests a peer-to-peer review, preparation is crucial for success.

Before the Call

Provide your doctor with:

  • Concise case summary (1-2 paragraphs)
  • Your availability windows for scheduling
  • Key points to emphasize:
    • Relapsing disease activity
    • Prior therapy failures with specific details
    • Functional impact and treatment goals

During Peer-to-Peer Review

Your physician should be prepared to discuss:

  • Clinical rationale for Kesimpta over alternatives
  • Specific reasons other DMTs failed or caused intolerance
  • Patient-specific factors supporting this choice
  • Safety monitoring plan

Counterforce Health helps providers prepare for these conversations by analyzing denial patterns and crafting targeted responses that address payer-specific concerns. Their platform can identify the most effective clinical arguments for your specific case.

After-Visit Documentation

Proper documentation after your appointment ensures nothing falls through the cracks.

What to Save

  • Copy of the prior authorization submission
  • Medical necessity letter draft
  • Supporting documentation sent to Humana
  • Confirmation of submission (fax confirmation, portal screenshot)

Portal Communication Strategy

Use your patient portal effectively:

  • Message your provider if you remember additional details
  • Request copies of all submitted documents
  • Ask for updates on submission status
  • Clarify next steps if additional information is needed

Timeline Tracking

Keep a simple log:

  • Submission date
  • Expected response timeframe (typically 15-30 days)
  • Follow-up date if no response
  • Appeal deadline if denied

Respectful Persistence and Follow-Up

Appropriate follow-up keeps your case moving without overwhelming your healthcare team.

Follow-Up Cadence

  • Week 1-2: Confirm submission received
  • Week 3-4: Check on status if no response
  • After denial: Discuss appeal strategy within 48 hours

Escalation Strategy

If facing delays or denials:

  1. Request expedited review if treatment delay risks harm
  2. Ask for supervisor involvement at Humana
  3. Consider external appeal through New York state process
  4. Contact Community Health Advocates at 888-614-5400 for free assistance

How to Communicate Politely

  • "I wanted to check on the status of my Kesimpta prior authorization"
  • "Could you help me understand what additional information might strengthen the request?"
  • "I'm concerned about treatment delays—is an expedited review possible?"

Appeals Process in New York

New York residents have strong appeal rights when Humana denies coverage.

Internal Appeal (First Step)

  • Timeline: 60 days from denial to file
  • Process: Submit through Humana member portal or by mail
  • Required: Denial letter, supporting documentation, provider letter

External Appeal (New York State)

If internal appeal fails, you can request independent review:

  • Timeline: 4 months from final denial
  • Cost: $25 (waived for Medicaid/financial hardship)
  • Process: File with NY Department of Financial Services
  • Review: Independent medical experts evaluate your case

Expedited Appeals

For urgent situations where delay could harm your health:

  • Timeline: 72 hours for standard, 24 hours for urgent drug needs
  • Eligibility: Serious health risk from treatment delay
  • Process: Request through same channels, mark "expedited"

Community Health Advocates at 888-614-5400 provides free assistance with both internal and external appeals for all New Yorkers.

FAQ: Common Questions

Q: How long does Humana prior authorization take in New York? A: Standard prior authorization typically takes 15-30 days. Expedited reviews are completed within 72 hours when medical urgency is documented.

Q: What if Kesimpta is non-formulary on my Humana plan? A: You can request a formulary exception with medical necessity documentation. Your doctor must demonstrate why preferred alternatives are inappropriate.

Q: Can I request an expedited appeal if denied? A: Yes, if treatment delay could seriously harm your health. Both Humana's internal process and New York's external appeal offer expedited timelines.

Q: Does step therapy apply if I've failed therapies outside New York? A: Prior therapy failures from other states should count toward step therapy requirements. Ensure your doctor documents all previous treatments with dates and outcomes.

Q: What happens if my hepatitis B screening is positive? A: Active hepatitis B infection is a contraindication for Kesimpta. Your doctor will need to treat the infection first or consider alternative MS therapies.

Q: Can I use manufacturer copay assistance with Humana? A: Copay cards may have restrictions with government plans. Check the Kesimpta savings program for current eligibility.

From Our Advocates: We've seen cases where patients initially denied for Kesimpta succeeded on appeal by providing comprehensive documentation of prior therapy failures and functional impact. The key was working closely with their neurologist to gather detailed treatment history and submit a thorough medical necessity letter that directly addressed the plan's criteria.

Counterforce Health specializes in turning insurance denials into successful appeals by analyzing payer-specific requirements and crafting evidence-based responses. Their platform helps patients and providers navigate complex prior authorization processes more effectively, reducing delays in accessing critical medications like Kesimpta.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical advice. Always consult your healthcare provider for personalized treatment decisions. Insurance coverage varies by plan and individual circumstances. For official guidance on appeals and coverage rights in New York, contact the NY Department of Financial Services or Community Health Advocates at 888-614-5400.

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