By Counterforce Health Team in Strensiq (asfotase alfa) —

Work With Your Doctor to Get Strensiq (Asfotase Alfa) Approved by Blue Cross Blue Shield in Washington: Complete Provider Collaboration Guide

Answer Box: Your Path to Strensiq Approval in Washington

To get Strensiq (asfotase alfa) covered by Blue Cross Blue Shield in Washington, you'll need: (1) documented pediatric-onset hypophosphatasia with genetic/biochemical confirmation, (2) a comprehensive medical necessity letter from your specialist, and (3) baseline ophthalmology and renal imaging. Start by scheduling a visit with your pediatric endocrinologist or geneticist to review Blue Cross Blue Shield's specific prior authorization criteria. If denied, Washington's external review process through Independent Review Organizations (IROs) has strong patient protections. Contact the Washington Insurance Commissioner at 1-800-562-6900 for free appeals guidance.

Table of Contents

  1. Set Your Goal: Understanding Blue Cross Blue Shield Requirements
  2. Prepare for Your Provider Visit
  3. Build Your Evidence Kit
  4. Medical Necessity Letter Structure
  5. Support Your Provider During Peer-to-Peer Reviews
  6. Document Everything: After-Visit Strategy
  7. Practice Respectful Persistence
  8. Appeals Playbook for Washington
  9. Common Denial Reasons & Solutions
  10. FAQ

Set Your Goal: Understanding Blue Cross Blue Shield Requirements

Your partnership with your healthcare provider centers on meeting Blue Cross Blue Shield's specific criteria for Strensiq approval. Here's what you're working toward together:

Coverage Requirements at a Glance

Requirement What It Means Where to Find It
Age Restriction Under 18 years OR documented pediatric onset Blue Cross Blue Shield Policy
Genetic Testing ALPL gene mutations OR biochemical confirmation FDA Prescribing Information
Specialist Consultation Geneticist or pediatric endocrinologist involvement Blue Cross Blue Shield PA criteria
Baseline Monitoring Ophthalmology exam and renal ultrasound Common PA Criteria
Clinical Severity Documented functional impact and disease progression Medical necessity standards

Your Role in the Partnership

You'll help your provider by:

  • Gathering comprehensive medical history
  • Documenting functional limitations clearly
  • Coordinating between specialists
  • Following up on required testing
  • Staying organized with appeals if needed

Prepare for Your Provider Visit

Symptom Timeline Documentation

Create a detailed timeline including:

Early Signs (if applicable)

  • Premature tooth loss in primary teeth
  • Delayed walking or motor milestones
  • Frequent fractures or bone pain
  • Growth delays or failure to thrive

Current Symptoms

  • Daily functional limitations
  • Pain levels and triggers
  • Respiratory issues or chest deformity
  • Seizures or neurological symptoms

Impact on Quality of Life

  • School attendance and performance
  • Physical activity limitations
  • Sleep disruption
  • Family stress and caregiving burden

Previous Treatment History

Document all therapies attempted:

  • Calcium and vitamin D supplementation
  • Physical therapy interventions
  • Orthopedic procedures or devices
  • Pain management approaches
  • Outcomes and why treatments failed
Tip: Bring copies of growth charts, X-rays, and lab results from other providers to give your specialist a complete picture.

Build Your Evidence Kit

Essential Laboratory Results

Your provider will need:

Biochemical Markers

  • Serum alkaline phosphatase (must be below age-specific normal range)
  • Plasma pyridoxal 5'-phosphate (PLP) levels
  • Urine phosphoethanolamine (PEA) if available
  • Calcium and phosphate levels

Genetic Testing

  • ALPL gene sequencing results
  • Family history of hypophosphatasia
  • Carrier testing for parents if relevant

Imaging Documentation

Collect recent studies showing:

  • Skeletal survey or targeted X-rays
  • Bone density scans (DEXA) if age-appropriate
  • Chest imaging showing rachitic changes
  • Renal ultrasound (baseline requirement)

Published Guidelines Support

Your provider may reference:

Medical Necessity Letter Structure

Key Components Your Provider Should Include

Patient Demographics and Diagnosis

  • Age, weight, and HPP onset timing
  • ICD-10 codes for hypophosphatasia
  • Date of initial diagnosis
  • Confirming specialist consultations

Clinical Rationale

  • Biochemical evidence of alkaline phosphatase deficiency
  • Genetic confirmation when available
  • Radiographic findings consistent with HPP
  • Functional impact on growth and development

Treatment History and Failures

  • Conservative therapies attempted
  • Lack of disease-modifying alternatives
  • Contraindications to other approaches
  • Progressive disease despite supportive care

Strensiq-Specific Justification

  • FDA approval for pediatric-onset HPP
  • Dosing plan (6 mg/kg/week subcutaneous)
  • Expected clinical outcomes
  • Monitoring plan for safety and efficacy

Supporting Documentation Checklist

Help your provider gather:

  • Complete medical records
  • Laboratory results (ALP, PLP, genetics)
  • Imaging studies with radiologist reports
  • Growth charts and developmental assessments
  • Prior authorization forms completed
  • Baseline ophthalmology and renal studies

Support Your Provider During Peer-to-Peer Reviews

When Blue Cross Blue Shield Requests Clinical Discussion

If your prior authorization is initially denied, Blue Cross Blue Shield may offer a peer-to-peer review between your physician and their medical director.

How You Can Help:

  • Provide flexible scheduling for your provider
  • Summarize your most compelling clinical points
  • Offer to be available for additional questions
  • Document the conversation outcomes

Key Talking Points for Your Provider

Medical Necessity Arguments:

  • No FDA-approved alternatives for HPP
  • Progressive nature without treatment
  • Established efficacy in pediatric trials
  • Quality of life improvements documented

Clinical Evidence:

  • Objective biomarker improvements
  • Radiographic healing potential
  • Respiratory function preservation
  • Growth velocity enhancement
From our advocates: Families who prepare a one-page clinical summary for their provider before peer-to-peer calls often see better outcomes. Include the three strongest pieces of evidence supporting medical necessity and any urgent clinical concerns that make delays risky.

Document Everything: After-Visit Strategy

What to Save and Organize

Clinical Documentation

  • Visit notes with HPP assessment
  • Laboratory orders and results
  • Imaging referrals and reports
  • Prescription details and dosing

Insurance Communications

  • Prior authorization submissions
  • Denial letters with specific reasons
  • Appeals correspondence
  • Phone call logs with reference numbers

Using Patient Portals Effectively

Message Your Provider When:

  • Insurance requests additional information
  • New symptoms develop during review
  • You receive denial or approval notifications
  • External specialists provide relevant results

Include in Portal Messages:

  • Specific insurance request details
  • Deadline dates for responses
  • Your availability for additional visits
  • Questions about next steps

Practice Respectful Persistence

Appropriate Follow-Up Cadence

During Prior Authorization Review (typically 7-14 days):

  • Week 1: Confirm submission received
  • Week 2: Check on review status
  • Beyond 2 weeks: Contact insurance directly

If Denied - Internal Appeal Phase:

  • Day 1-3: Discuss appeal strategy with provider
  • Day 7: Submit comprehensive appeal
  • Day 21: Follow up on review timeline
  • Day 30: Prepare for potential denial

Escalation Strategies

When to Involve Higher Levels:

  • Multiple denials despite meeting criteria
  • Delays affecting clinical stability
  • Procedural errors in review process
  • Urgent medical circumstances

How to Escalate Professionally:

  • Document all previous interactions
  • Reference specific policy language
  • Request supervisor or medical director review
  • Consider involving patient advocacy resources

Appeals Playbook for Washington

Washington state provides robust consumer protections through the Office of the Insurance Commissioner.

Internal Appeals Process

Level 1 Appeal

  • Deadline: 180 days from denial
  • Timeline: 30 days for standard; 72 hours for expedited
  • Submission: Blue Cross Blue Shield appeals department
  • Requirements: Written request with additional clinical evidence

Level 2 Appeal (if available)

  • Deadline: 30-60 days from Level 1 denial
  • Timeline: 30 days for decision
  • Requirement: Different medical reviewer
  • Format: Written submission only

External Review (IRO Process)

Eligibility Requirements:

  • Both internal appeals exhausted
  • Medical necessity dispute
  • Financial responsibility of $500 or more

Timeline and Process:

  • Filing deadline: 4 months from final internal denial
  • Decision timeline: 30 days standard; 72 hours expedited
  • Cost: Free to patient
  • Authority: Decision binding on insurer if favorable

Contact for Help: Washington Office of the Insurance Commissioner Phone: 1-800-562-6900 Website: insurance.wa.gov

Note: External reviews in Washington overturn approximately 40% of insurance denials, making this a valuable option for medically necessary treatments.

Common Denial Reasons & Solutions

Denial Reason Solution Strategy
"Adult-onset HPP not covered" Provide pediatric onset documentation before age 18
"Insufficient genetic confirmation" Submit biochemical evidence (low ALP, high PLP) and clinical criteria
"Experimental/investigational" Reference FDA approval and pediatric indication
"Lack of medical necessity" Document functional decline and failed conservative therapies
"Dosing above guidelines" Justify with clinical response data and FDA labeling flexibility
"Missing baseline studies" Complete ophthalmology exam and renal ultrasound

Strengthening Your Appeal

Clinical Evidence to Emphasize:

  • Progressive bone disease without treatment
  • Lack of alternative disease-modifying therapies
  • Established safety profile in pediatric populations
  • Objective measures of disease severity

Documentation That Helps:

  • Growth velocity charts showing decline
  • Radiographic progression over time
  • Quality of life questionnaires
  • Specialist consensus on treatment need

Counterforce Health: Expert Appeals Support

When navigating complex prior authorization denials, Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into targeted, evidence-backed appeals. Their platform analyzes denial letters, plan policies, and clinical notes to identify specific denial reasons and draft point-by-point rebuttals aligned with each payer's requirements. For medications like Strensiq, they pull the right citations from FDA labeling, peer-reviewed studies, and specialty guidelines, weaving them into appeals with required clinical facts and operational details that payers expect.

FAQ

How long does Blue Cross Blue Shield prior authorization take for Strensiq in Washington? Standard reviews take 7-14 business days. Expedited reviews for urgent cases are completed within 72 hours. Your provider can request expedited review if delays could jeopardize your health.

What if Strensiq is not on my Blue Cross Blue Shield formulary? Strensiq requires prior authorization even when covered. If it's non-formulary, your provider can request a formulary exception with medical necessity documentation and evidence that formulary alternatives are inappropriate.

Can I request an expedited appeal if Strensiq is denied? Yes, if your health could be in serious jeopardy without treatment. Washington state requires expedited reviews within 72 hours when urgent circumstances exist.

Does step therapy apply to Strensiq? Blue Cross Blue Shield may require documentation that supportive therapies (calcium, vitamin D, physical therapy) have been tried, but there are no FDA-approved alternatives to require as step therapy for HPP.

What happens if my provider leaves during the appeals process? Contact your new provider immediately to transfer medical records and continue the appeal. The clinical documentation travels with your case, but you may need new prior authorization forms.

How much does Strensiq cost without insurance? Annual costs can exceed $500,000-$4.9 million depending on weight and dosing. Alexion Access Navigator offers patient assistance programs and copay support for eligible families.

Can I appeal to the state if Blue Cross Blue Shield denies my external review request? Contact the Washington Insurance Commissioner at 1-800-562-6900 if you believe the external review process was handled incorrectly. They provide free consumer advocacy and can investigate procedural issues.

What documentation should I keep during the appeals process? Save all denial letters, appeal submissions, medical records, insurance communications, and phone call logs with reference numbers. Organize by date and keep both physical and digital copies.

Sources & Further Reading

Medical Disclaimer: This information is for educational purposes only and does not constitute medical advice. Always consult with qualified healthcare providers about your specific medical situation. Insurance coverage decisions depend on individual policy terms and clinical circumstances. For personalized appeals assistance, consider consulting with Counterforce Health or other qualified patient advocacy services.

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