Gastroenterology prior authorization at Healthfirst

Healthfirst gastroenterology PA at a glance

Healthfirst reviews gastroenterology PA submissions against its medical policy library, with rules drawn primarily from AGA / ACG / Cochrane IBD guidelines + STRIDE-II treat-to-target. Healthfirst-specific context: Provider-sponsored not-for-profit; largest Medicaid MCO in NY State (~1.8M members). Owned by ~30 NY hospital systems. NY DFS oversight. NY State Fair Hearing is escalation path for Medicaid denials; commercial appeals go to DFS external appeal program.

Documentation packet — what to send

• IBD diagnosis confirmed by endoscopy/biopsy
• Disease distribution and severity
• Prior conventional therapies tried
• Steroid course (drug, dose, taper attempts)
• Therapeutic drug monitoring labs where applicable
• Tuberculosis + hepatitis B screening prior to biologic

Common denial patterns to pre-empt

Patterns observed in gastroenterology across payers, and where Healthfirst's book of business overlaps:

• Step therapy through 5-ASA / immunomodulators / steroids first
• Switching between mechanism-of-action classes without documented failure
• Therapeutic drug monitoring not done before dose escalation
• Endoscopic disease not documented

Appeal angles when Healthfirst denies

• AGA / ACG guidelines for IBD positioning
• Endoscopic Mayo subscore or SES-CD documenting active disease
• Failure of prior biologic by mechanism of action (anti-TNF, anti-integrin, anti-IL-12/23, JAK)
• Steroid-dependence or steroid-refractory disease

Peer-to-peer prep

• Pull the most recent endoscopy report with photos if possible
• Quantify steroid dependence (mg of prednisone per year, taper attempts)
• Reference STRIDE-II treat-to-target if requesting mechanism switch
• Cite specific endoscopic scoring (Mayo, SES-CD) and the date

Drug-specific PA criteria at Healthfirst

Deep dives on each drug's PA criteria at Healthfirst:

• adalimumab
• infliximab
• ustekinumab
• risankizumab
• tofacitinib
• upadacitinib