Work With Your Doctor to Get StrataGraft Approved by Aetna CVS Health in North Carolina: Complete Provider Partnership Guide
Answer Box: Your Path to StrataGraft Coverage
Getting StrataGraft approved by Aetna CVS Health in North Carolina requires strong provider partnership. Your burn specialist must document that you're an adult with deep partial-thickness thermal burns requiring surgery, and that autograft alone isn't optimal. First step today: Schedule a visit to review your burn assessment, discuss StrataGraft as an alternative to autograft, and prepare documentation for Aetna's medical benefit prior authorization. If denied, you have 180 days for internal appeals and 120 days for North Carolina's Smart NC external review after final denial.
Table of Contents
- Set Your Coverage Goal
- Prepare for Your Provider Visit
- Build Your Evidence Kit
- Support Your Doctor's Medical Necessity Letter
- Assist with Peer-to-Peer Reviews
- Document Everything After Your Visit
- Practice Respectful Persistence
- Appeals in North Carolina
- Common Denial Reasons & Solutions
- FAQ
Set Your Coverage Goal
StrataGraft is a living skin substitute that helps deep partial-thickness burn wounds heal without requiring as much autograft surgery. Aetna CVS Health covers StrataGraft only under specific medical criteria and only through the medical benefit, not pharmacy.
What Approval Requires
Your burn specialist must document that you meet these core criteria:
- Age 18 or older (FDA indication is adults only)
- Deep partial-thickness thermal burns with intact dermal elements
- Surgical intervention is clinically indicated (conservative care isn't sufficient)
- Autograft alone is suboptimal due to limited donor sites, medical risks, or functional concerns
- No active infection at treatment site
- Treatment at an approved burn center or hospital facility
Note: StrataGraft is billed under HCPCS code J7353 as a medical procedure, not dispensed through CVS Caremark or specialty pharmacy.
How You'll Partner with Your Provider
Your role is to help your burn specialist build the strongest possible case by:
- Providing complete treatment history and functional impact details
- Gathering supporting documentation from other providers
- Understanding Aetna's specific requirements to guide discussions
- Supporting peer-to-peer reviews and appeals when needed
Prepare for Your Provider Visit
Document Your Burn History Timeline
Create a detailed chronology including:
Initial Injury Details:
- Date, time, and mechanism of burn (flame, scald, contact)
- Immediate treatment received (emergency room, burn center)
- Initial burn assessment and depth determination
Treatment History:
- All wound care approaches tried (topical antimicrobials, dressings, negative pressure)
- Dates, duration, and response to each treatment
- Any complications (infection, delayed healing, pain levels)
- Previous surgeries or procedures attempted
Current Functional Impact:
- Pain levels and management needs
- Mobility limitations or range-of-motion issues
- Impact on work, daily activities, or quality of life
- Concerns about scarring or contracture risk
Prepare Key Questions
Come ready to discuss:
- Why StrataGraft is preferred over standard autgraft for your specific burns
- What donor site limitations or risks apply to your case
- Timeline for treatment and expected recovery
- How this fits into your overall burn care plan
Build Your Evidence Kit
Gather Medical Documentation
Essential Records:
- All burn assessment notes with depth and TBSA (total body surface area) measurements
- Wound photographs showing burn characteristics
- Laboratory results and imaging studies
- Documentation of failed conservative treatments
- Any previous surgical reports or procedures
From Other Providers:
- Emergency department records from initial injury
- Primary care notes about wound healing progress
- Physical therapy assessments if applicable
- Pain management documentation
Research Supporting Guidelines
Help your provider by identifying relevant clinical evidence:
- FDA labeling for StrataGraft showing approved indications
- American Burn Association guidelines on burn depth assessment and surgical timing
- Published studies on StrataGraft outcomes versus autgraft
Tip: Print key pages from FDA documentation to bring to your appointment - this helps your provider reference official language in their letter.
Support Your Doctor's Medical Necessity Letter
Key Elements to Discuss
Work with your burn specialist to ensure their letter addresses:
Burn Assessment Section:
- Explicit confirmation of "deep partial-thickness thermal burn with intact dermal elements"
- Specific anatomical locations and measurements in cm²
- TBSA percentage using standard assessment methods
- ICD-10 codes (T20-T25 series plus T31.x for TBSA)
Surgical Indication:
- Clear statement that "surgical intervention is clinically indicated"
- Why conservative management is insufficient
- Timeline considerations for optimal outcomes
Autograft Rationale:
- Specific reasons why standard autgraft alone is suboptimal:
- Limited donor site availability
- Medical comorbidities affecting healing
- Functional or cosmetic concerns
- Risk of additional donor site morbidity
StrataGraft Medical Necessity:
- How StrataGraft reduces need for autgraft harvesting
- Expected outcomes based on clinical trials
- Alignment with FDA-approved indication
Supporting Evidence to Provide
Help your provider include:
- Clinical photographs with measurements
- Wound healing progression notes
- Documentation of any complications or delays
- Functional assessment results
Assist with Peer-to-Peer Reviews
If Aetna's medical director requests a peer-to-peer discussion, you can support your provider by:
Preparing Key Talking Points
For Your Provider to Emphasize:
- 96% of StrataGraft-treated sites in clinical trials healed without requiring autgraft
- Comparable closure rates to autgraft (83.1% vs 86%) but without donor site surgery
- FDA approval specifically for deep partial-thickness thermal burns in adults
- Patient-specific factors making autgraft suboptimal in this case
Offering Availability
- Provide your provider with your availability for urgent calls
- Ensure they have your current contact information
- Be prepared to provide additional clinical details if requested during the call
Creating a Concise Case Summary
Help your provider prepare a 2-3 sentence summary: "This [age]-year-old adult has [X]% TBSA deep partial-thickness thermal burns involving [specific sites]. Standard autgraft would require donor site harvest with associated morbidity. StrataGraft is medically necessary to achieve durable closure while avoiding donor site surgery, consistent with FDA indication and clinical trial evidence."
Document Everything After Your Visit
Save All Communications
From Your Provider's Office:
- Copies of prior authorization submissions
- Medical necessity letters and supporting documentation
- Any correspondence with Aetna
- Peer-to-peer call summaries
From Aetna:
- Initial authorization decisions (approval or denial)
- Detailed denial letters with specific reasons
- Appeal acknowledgments and decisions
- Any requests for additional information
Use Patient Portal Messaging
When following up with your provider:
- Be specific about what you need ("Can you check on the PA status for StrataGraft?")
- Include relevant reference numbers or dates
- Ask for copies of any new documentation submitted
Practice Respectful Persistence
Appropriate Follow-Up Cadence
Week 1-2 after submission: Check with provider's office about initial response Week 3-4: If no decision, ask provider to call Aetna for status update After denial: Discuss appeal options within 48 hours
How to Escalate Politely
With Your Provider's Office:
- "I want to make sure we don't miss any deadlines for appeals. Can we schedule a brief call to discuss next steps?"
- "Would it be helpful if I gathered any additional documentation for the appeal?"
Requesting Provider Action:
- "The denial letter mentions [specific criterion]. Could you help me understand how we can address this in an appeal?"
- "Would you be available for a peer-to-peer review if Aetna requests one?"
Appeals in North Carolina
If Aetna denies coverage, North Carolina offers strong appeal rights through both internal and external review processes.
Aetna Internal Appeals
Timeline: You have 180 days from the denial date to file an internal appeal Levels: Most Aetna plans use a two-level internal appeal process Decision Time: 30 calendar days for standard appeals, 36-72 hours for expedited appeals
How to File:
- Use Aetna's member appeal form (available on denial letter)
- Submit online through member portal, by mail, or fax as specified
- Include updated medical necessity letter addressing each denial reason
North Carolina Smart NC External Review
After exhausting Aetna's internal appeals, you can request independent external review through Health Insurance Smart NC.
Eligibility Requirements:
- Must have a state-regulated plan (not self-funded employer plans)
- Must complete all required internal appeals first
- Denial must be based on medical necessity or experimental treatment determination
Timeline:
- 120 days from final internal denial to request external review
- 45 days for standard external review decision
- 4 business days for expedited external review in urgent situations
How to File: Contact Smart NC at NC Department of Insurance by phone at 1-855-408-1212 for free advocacy and assistance with your external review request.
Important: Smart NC's decision is binding on Aetna - if they overturn the denial, your insurer must provide coverage within 3 business days.
Common Denial Reasons & Solutions
| Denial Reason | How to Address | Supporting Documentation |
|---|---|---|
| "Not medically necessary" | Emphasize autgraft limitations and StrataGraft's FDA indication | Updated letter with patient-specific rationale, clinical photos |
| "Experimental/investigational" | Reference FDA approval and clinical trial data | FDA labeling, published studies, payer policy updates |
| "Alternative available" | Document why autgraft alone is suboptimal | Donor site assessment, comorbidity documentation |
| "Billing error" | Confirm J7353 code and medical benefit billing | Corrected claim with proper HCPCS coding |
| "Insufficient documentation" | Provide complete clinical records | Burn assessment, treatment history, wound measurements |
FAQ
How long does Aetna CVS Health prior authorization take in North Carolina? Standard decisions typically take 30 calendar days. Expedited requests (when delay would jeopardize health) must be decided within 36-72 hours.
What if StrataGraft is non-formulary on my plan? StrataGraft is covered under the medical benefit, not pharmacy formulary. Your provider should submit to the medical benefit department, not CVS Caremark.
Can I request an expedited appeal? Yes, if waiting for standard appeal timing would seriously jeopardize your life, health, or ability to regain function. Your burn specialist must document the urgency.
Does step therapy apply if I've tried treatments outside North Carolina? Yes, prior treatment failures from other states count. Provide documentation from all previous providers about treatments tried and outcomes.
What if my employer plan is self-funded? Self-funded ERISA plans may not be eligible for North Carolina's external review. Check with Smart NC at 1-855-408-1212 to confirm your plan's eligibility.
How much does StrataGraft cost if not covered? StrataGraft is only available through hospital/burn center facilities, not retail pharmacies. Costs vary by institution and are typically billed per square centimeter of coverage.
When insurance denials seem overwhelming, remember that Counterforce Health helps patients, clinicians, and specialty pharmacies turn denials into targeted, evidence-backed appeals. Their platform analyzes denial letters and plan policies to draft point-by-point rebuttals that align with each payer's specific requirements, potentially saving valuable time in your appeal process.
Working closely with your burn specialist gives you the best chance of getting StrataGraft approved. Your provider has the clinical expertise to make the medical case, while you can help ensure all documentation is complete and deadlines are met. In North Carolina, the combination of strong provider partnership and robust state appeal rights through Smart NC creates multiple pathways to coverage when clinical criteria are met.
Sources & Further Reading
- Aetna CVS Health Medical Policy for Bioengineered Skin Substitutes
- FDA StrataGraft Product Information
- North Carolina Smart NC External Review Process
- Aetna Provider Appeals Process
- North Carolina State Health Plan Appeal Forms
This guide is for educational purposes only and does not constitute medical or legal advice. Coverage decisions depend on individual medical circumstances and specific plan terms. Always consult with your healthcare provider and insurance plan directly for personalized guidance.
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