Why MA Plans Denies Biologic Therapy (Autoimmune)
Step therapy not completed (conventional DMARDs first)
Prior biologic trial not documented
Biosimilar required before brand-name biologic
Know Medicare Advantage's Criteria
Medicare Advantage plans must cover all services covered by Original Medicare (CMS NCDs and LCDs) but may require prior auth. Plans use various criteria including InterQual, MCG, and proprietary guidelines.
Key policies to know:
- Must cover all services covered by Original Medicare
- Can require prior authorization not required by Original Medicare
- CMS NCDs and LCDs serve as coverage floor
- Organization determinations must be issued within 14 days (72 hours for expedited)
MA Plans's Specific Approach to Biologic Therapy (Autoimmune)
Applicable Policy
CMS does not have specific NCDs for most biologics -- covered under Part B (infused) or Part D (self-injected)
How MA Plans Typically Denies This
MA plans apply their own formulary for Part D biologics and may have different step therapy than commercial plans. Part B biologics (infused) are generally covered if medically necessary but MA plans may require prior auth.
Your Strategy for This Payer
For Part B biologics, emphasize that coverage follows Medicare guidelines. For Part D, you're subject to the plan's formulary. File a coverage determination request and cite the Part D regulations requiring exceptions when formulary drugs are not appropriate.
Key Phrase to Use on the Call
"This biologic is medically necessary and meets Medicare coverage criteria. The patient has documented failure of formulary alternatives, supporting a coverage exception under the Part D exception process."
Building Your Medical Necessity Argument
Document failure, intolerance, or contraindication to step therapy agents
Note disease activity scores (DAS28, CDAI, PASI)
If biosimilar switch requested, document clinical reason for brand
Reference comorbidities that limit alternative treatments
P2P Call Tips for MA Plans
Cite the relevant CMS NCD or LCD -- MA plans cannot deny what Medicare covers
If the service has a CMS NCD, that trumps the MA plan's internal criteria
Reference CMS regulations on MA coverage obligations
Request expedited determination if clinical urgency exists
Guidelines to Reference
- ACR Guidelines for Rheumatoid Arthritis Treatment
- AGA Guidelines for Biologic Therapy in IBD
- AAD Guidelines for Biologic Therapy in Psoriasis
Relevant CPT Codes
Specialty: Rheumatology / Gastroenterology / Dermatology
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