By Counterforce Health Team in Voxzogo (vosoritide) —

A Realistic Voxzogo Approval Scenario with Cigna in Virginia (From Request to Yes)

Answer Box: Getting Voxzogo Covered by Cigna in Virginia

To get Voxzogo (vosoritide) covered by Cigna in Virginia for pediatric achondroplasia, you need: confirmed FGFR3 genetic testing, open growth plates documentation, and a pediatric endocrinologist prescriber. Most approvals take 72 hours to 15 days with complete documentation. If denied, Virginia's external review process through the State Corporation Commission has strong patient protections. Start today: Call your pediatric endocrinologist to request FGFR3 testing and growth plate imaging, then contact BioMarin RareConnections at 1-833-VOXZOGO for prior authorization support.

Table of Contents

Patient Profile: Emma's Story

Emma is a 4-year-old girl from Richmond, Virginia, diagnosed with achondroplasia at birth. Her parents, Sarah and Mike, have commercial insurance through Mike's employer with Cigna coverage. Emma's pediatrician referred the family to a pediatric endocrinologist at Children's Hospital of Richmond when Emma's growth velocity began falling further behind typical achondroplasia curves.

Key Details:

  • Age: 4 years, 2 months
  • Diagnosis: Achondroplasia (clinical diagnosis at birth)
  • Current height: 85 cm (significantly below 3rd percentile)
  • Insurance: Cigna commercial PPO through employer
  • Location: Richmond, Virginia

Emma's parents learned about Voxzogo through the Little People of America support network and wanted to explore treatment options while Emma's growth plates remained open.

Pre-Authorization Preparation

Emma's pediatric endocrinologist, Dr. Martinez, began preparing for the Voxzogo prior authorization in January 2024. This preparation phase took approximately 3-4 weeks to complete all requirements.

Step 1: Genetic Testing Confirmation

Since Emma's diagnosis was based on clinical features alone, Dr. Martinez ordered FGFR3 genetic testing to confirm the molecular diagnosis required by Cigna's policy.

Timeline: 2 weeks for results Cost: Covered by insurance as diagnostic testing Result: Confirmed heterozygous FGFR3 c.1138G>A mutation

Step 2: Growth Plate Documentation

Dr. Martinez ordered X-rays of Emma's knees and wrists to document open epiphyses, as required by Cigna's medical necessity criteria.

Radiology Report Key Finding: "Open growth plates visible at distal femur, proximal tibia, and distal radius bilaterally, consistent with ongoing growth potential."

Step 3: Growth Data Collection

The team compiled 12 months of growth measurements showing Emma's declining growth velocity:

  • Baseline height velocity: 3.8 cm/year
  • Expected for achondroplasia: 4-5 cm/year
  • Expected for typical children her age: 6-7 cm/year

Step 4: Medical Necessity Letter

Dr. Martinez drafted a comprehensive letter addressing each point in Cigna's National Formulary PA policy:

Medical Necessity Letter Excerpt: "Emma meets all criteria for Voxzogo therapy: confirmed achondroplasia with FGFR3 mutation, age >2 years with documented open growth plates, declining growth velocity, and no planned limb-lengthening surgery. Early intervention is crucial as the treatment window closes when growth plates fuse."

Submission Process

Prior Authorization Packet Contents

Dr. Martinez's office submitted the PA request through Cigna's provider portal with these documents:

  1. Completed PA form (Cigna Growth Disorders - Voxzogo form)
  2. Medical necessity letter (3 pages)
  3. FGFR3 genetic test results
  4. Growth plate X-ray reports
  5. Growth charts and measurements (12 months)
  6. Clinical notes from endocrinology visits
  7. Prescription with weight-based dosing calculation

Submission Method

The practice used Cigna's online provider portal rather than fax to ensure tracking and faster processing. They also contacted BioMarin RareConnections for additional support with the PA process.

Submission Date: February 15, 2024 Confirmation Number: Received within 24 hours

Initial Outcome

Approval Timeline

Cigna approved Emma's Voxzogo prescription on February 18, 2024—just 3 business days after submission.

Approval Details:

  • Duration: 12 months
  • Quantity: 30-day supply with 3 refills
  • Pharmacy: Express Scripts specialty pharmacy
  • Patient cost-sharing: $50 copay per month (reduced to $0 with BioMarin co-pay assistance)

Why This Approval Succeeded

The approval was swift because the submission included every element from Cigna's updated March 2024 policy:

✅ Confirmed achondroplasia diagnosis with genetic testing ✅ Pediatric patient ≥2 years with open epiphyses ✅ Specialist prescriber (pediatric endocrinologist) ✅ No concurrent limb-lengthening surgery ✅ Complete documentation of growth history and medical necessity

Note: This represents an ideal scenario. Not all cases proceed this smoothly, which is why understanding the appeal process is crucial.

Appeal Strategy

While Emma's case was approved initially, many families face denials. Here's the strategy that successful appeals typically follow in Virginia:

Common Denial Reasons and Solutions

Denial Reason Solution Documentation Needed
Missing genetic confirmation Submit FGFR3 test results Lab report showing pathogenic variant
Growth plates not documented Provide imaging reports X-ray with radiologist interpretation
Prescriber not specialist Transfer to endocrinologist Consultation note from qualified specialist
Insufficient growth data Submit comprehensive charts 6-12 months of measurements

Internal Appeal Process

If denied, families have 180 days to file an internal appeal with Cigna. The process involves:

  1. Review denial letter carefully for specific reasons
  2. Address each denial point with additional evidence
  3. Submit appeal via Cigna member portal or certified mail
  4. Request peer-to-peer review between prescriber and Cigna medical director
  5. Await decision within 30 days (15 days for urgent cases)

Resolution and Approval

Emma began Voxzogo therapy in March 2024. Her first 6-month follow-up showed:

  • Height increase: 3.2 cm (compared to 1.8 cm in previous 6 months)
  • Improved growth velocity: From 3.8 to 5.4 cm/year
  • No significant side effects: Mild injection site reactions only
  • Successful reauthorization: Approved for another 12 months based on documented benefit

Reauthorization Requirements

For Emma's renewal, Dr. Martinez provided:

  • Updated growth measurements showing benefit
  • Documentation of medication adherence
  • Confirmation that growth plates remain open
  • Assessment of any adverse effects

Counterforce Health specializes in helping families navigate complex insurance approvals like Voxzogo, turning denials into evidence-backed appeals that align with each payer's specific requirements. Their platform analyzes denial letters and drafts targeted rebuttals using the right clinical evidence and policy language.

What We'd Do Differently

Based on this experience and similar cases, here are key improvements for future submissions:

Earlier Preparation

  • Start genetic testing as soon as Voxzogo is considered (2-3 weeks for results)
  • Establish specialist care early in the process
  • Document growth patterns for at least 6 months before submission

Enhanced Documentation

  • Include functional impact assessments (mobility, daily activities)
  • Add psychosocial considerations (peer interactions, self-esteem)
  • Provide family medical history if relevant

Proactive Communication

  • Contact BioMarin RareConnections before submission for PA template review
  • Establish relationship with Cigna case manager for complex cases
  • Consider peer-to-peer discussion even before denial to address concerns

Templates and Checklists

Pre-Submission Checklist

Required Documentation:

  • FGFR3 genetic test results
  • Growth plate imaging (X-ray or MRI)
  • 6-12 months of growth measurements
  • Specialist consultation notes
  • Medical necessity letter
  • Prescription with dosing calculations
  • Insurance verification and benefits check

Timeline Planning:

  • Genetic testing: 2-3 weeks
  • Imaging studies: 1 week
  • Growth data compilation: Ongoing
  • PA submission preparation: 1 week
  • Cigna review: 3-15 business days

Medical Necessity Letter Template

A successful letter should address:

  1. Patient demographics and insurance information
  2. Confirmed diagnosis with genetic evidence
  3. Clinical presentation and growth history
  4. Treatment rationale and expected benefits
  5. Alternative treatments considered and rejected
  6. Monitoring plan and safety considerations

Virginia-Specific Appeal Rights

Virginia provides strong protections for patients facing insurance denials through the State Corporation Commission Bureau of Insurance.

External Review Process

If Cigna's internal appeal fails, Virginia residents can request external review:

  • Timeline: Must file within 120 days of final denial
  • Process: Independent medical review by qualified specialists
  • Cost: Free to patients
  • Decision: Binding on Cigna if overturned
  • Expedited option: Available for urgent cases (72-hour decision)

Filing External Review

Submit Form 216-A External Review Request to:

Virginia Bureau of Insurance
State Corporation Commission
P.O. Box 1157
Richmond, VA 23218

Include denial letters, medical records, and supporting evidence from your specialist.

Consumer Assistance

Virginia's Managed Care Ombudsman provides free help with insurance disputes:

  • Phone: 1-877-310-6560
  • Services: Appeal guidance, form assistance, informal resolution
  • Eligibility: All Virginia residents with regulated health plans

FAQ

How long does Cigna prior authorization take for Voxzogo in Virginia?

With complete documentation, most Cigna PA decisions are made within 3-15 business days. Expedited reviews (when medically urgent) are decided within 72 hours. Incomplete submissions may take longer due to requests for additional information.

What if Voxzogo is not on my Cigna formulary?

You can request a formulary exception by demonstrating medical necessity and lack of appropriate alternatives. Since no other FDA-approved drugs treat achondroplasia, formulary exceptions are often granted with proper documentation.

Can I get expedited approval if my child's growth plates are closing?

Yes. If your pediatric endocrinologist certifies that delay would significantly reduce treatment effectiveness, you can request expedited prior authorization (72-hour decision) and expedited appeals if needed.

Does step therapy apply to Voxzogo?

Generally no. Cigna's policy doesn't require trying other medications first since there are no FDA-approved alternatives for achondroplasia growth modification.

What if I've already paid out-of-pocket while appealing?

If your appeal is successful, Cigna must provide retroactive coverage and reimburse eligible out-of-pocket costs incurred during the appeal period. Keep all receipts and pharmacy documentation.

How much does Voxzogo cost with Cigna coverage?

Costs vary by plan design. Many patients pay $0-50 per month with BioMarin's co-pay assistance program, which covers up to $18,200 annually for eligible commercial insurance patients.

What happens at reauthorization?

Cigna requires annual reauthorization showing continued medical necessity, documented growth benefit, medication adherence, and confirmation that growth plates remain open. Most reauthorizations are approved when benefit is documented.

Can I continue Voxzogo during an appeal?

Virginia law requires insurers to continue coverage during internal appeals if the appeal is filed timely and the prescriber certifies ongoing medical necessity. This "continuation of benefits" protection helps avoid treatment interruptions.

This article provides educational information about insurance coverage and is not medical advice. Always consult your healthcare providers for medical decisions and your insurance company for coverage details. For assistance with Virginia insurance appeals, contact the State Corporation Commission Bureau of Insurance at 1-877-310-6560.

Sources & Further Reading

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