By Counterforce Health Team in Tegsedi (inotersen) —

Coding That Helps Get Tegsedi (inotersen) Approved by Cigna in Florida: ICD-10, HCPCS/J-Code, and NDC Guide

Answer Box: Getting Tegsedi (inotersen) Coded Correctly for Cigna Coverage in Florida

Fastest path to approval: Use ICD-10 code E85.1 (neuropathic heredofamilial amyloidosis), HCPCS J3490 (unclassified drugs) with NDC 72126-0007-02, and submit via Cigna's electronic PA system through Express Scripts/Accredo. Tegsedi requires prior authorization under the medical benefit (not pharmacy) with strict REMS enrollment and platelet monitoring documentation. First step today: Verify your Cigna plan handles Tegsedi as a medical drug using J3490 billing, then gather TTR genetic testing, baseline neuropathy scores, and recent platelet counts before PA submission.

Table of Contents

  1. Coding Basics: Medical vs. Pharmacy Benefit Paths
  2. ICD-10 Mapping for hATTR Polyneuropathy
  3. Product Coding: HCPCS, J-Code, and NDC Overview
  4. Clean Request Anatomy: Example PA Structure
  5. Frequent Coding Pitfalls and How to Avoid Them
  6. Verification with Cigna Resources
  7. Quick Audit Checklist
  8. Appeals Playbook for Florida
  9. FAQ: Common Coding Questions

Coding Basics: Medical vs. Pharmacy Benefit Paths

Tegsedi (inotersen) creates a unique coding challenge because it's a self-administered injectable that most payers, including Cigna, process under the medical benefit rather than standard pharmacy coverage.

Medical Benefit Path (Most Common)

  • Billing codes: HCPCS J3490 (unclassified drugs) or C9399 (hospital outpatient)
  • Processing: Through Cigna medical prior authorization, not Express Scripts pharmacy PA
  • Distribution: Often via Accredo specialty pharmacy shipping to provider or patient
  • Payment: Medical copay/deductible structure, not pharmacy copays

Pharmacy Benefit Path (Less Common)

  • Billing codes: NDC 72126-0007-02 directly
  • Processing: Express Scripts pharmacy PA system
  • Distribution: Specialty pharmacy network (Accredo)
  • Payment: Pharmacy benefit copay structure
Tip: Call Cigna at 1-800-882-4462 to confirm which benefit handles Tegsedi for your specific plan before coding claims.

ICD-10 Mapping for hATTR Polyneuropathy

The correct diagnosis coding is critical for Tegsedi approval, as Cigna's medical necessity criteria are tied to specific hereditary transthyretin amyloidosis presentations.

Primary ICD-10 Code

E85.1 - Neuropathic heredofamilial amyloidosis

  • Covers hereditary transthyretin-mediated (hATTR) amyloidosis with polyneuropathy
  • Required for all Tegsedi prior authorization requests
  • Must be supported by genetic testing showing pathogenic TTR variant

Supporting Documentation for E85.1

Your medical records should include these specific terms to support the diagnosis code:

  • Genetic confirmation: "Pathogenic variant in TTR gene confirmed by genetic testing"
  • Clinical manifestations: "Progressive peripheral sensory-motor polyneuropathy"
  • Staging assessment: FAP Stage 1-2 or PND score documentation
  • Neuropathy scores: mNIS+7 (modified Neuropathy Impairment Score +7) baseline values

Alternative Codes (When Applicable)

  • E85.4 - Organ-limited amyloidosis (if cardiac involvement documented)
  • E85.82 - Wild-type transthyretin-related amyloidosis (for non-hereditary cases)

Product Coding: HCPCS, J-Code, and NDC Overview

HCPCS/J-Code Information

Primary Code: J3490 - Unclassified drugs

  • Tegsedi does not have its own specific J-code as of 2025
  • Must specify "Tegsedi (inotersen) 284 mg/1.5 mL" in line description
  • Units: Typically 1 unit per 284 mg prefilled syringe

Alternative Code: C9399 - Unclassified drugs or biologicals

  • Used for hospital outpatient/OPPS billing
  • Same unit structure as J3490

NDC Number and Strength

NDC: 72126-0007-02

  • Tegsedi 284 mg/1.5 mL prefilled syringe
  • Single-strength product, no dose calculations needed
  • Weekly dosing: 1 syringe = 1 week of therapy

Units Calculation for Billing

Billing Scenario Units Description
Weekly dose 1 unit 1 syringe per week
28-day supply 4 units 4 syringes
84-day supply 12 units 12 syringes

Clean Request Anatomy: Example PA Structure

Here's how a properly coded Tegsedi prior authorization should look for Cigna in Florida:

Patient Information Section

Patient: [Name], DOB: [Date]
Cigna ID: [Member ID]
Diagnosis: E85.1 - Neuropathic heredofamilial amyloidosis
Prescriber: [Neurologist name and NPI]

Drug Information Section

Drug: Tegsedi (inotersen)
NDC: 72126-0007-02
Strength: 284 mg/1.5 mL prefilled syringe
Dose: 284 mg subcutaneous weekly
Quantity: 4 syringes per 28 days
HCPCS: J3490 (unclassified drugs)

Clinical Documentation Requirements

  • TTR genetic testing results showing pathogenic variant
  • Baseline neuropathy assessment (mNIS+7, Norfolk QoL-DN, or PND score)
  • Recent laboratory values (platelet count ≥100 × 10⁹/L, renal function)
  • REMS enrollment confirmation for patient, prescriber, and pharmacy

Frequent Coding Pitfalls and How to Avoid Them

1. Wrong Billing Units

Common Error: Billing per mg instead of per syringe Fix: Verify Cigna's unit definition - typically 1 unit = 1 syringe (284 mg)

2. Incorrect Diagnosis Codes

Common Error: Using generic neuropathy codes (G60.x) or non-specific amyloidosis codes Fix: Always use E85.1 for hereditary transthyretin amyloidosis with polyneuropathy

3. Missing NDC on Medical Claims

Common Error: Submitting J3490 without required NDC reporting Fix: Include NDC 72126-0007-02 with quantity and unit of measure

4. Quantity Over Limits

Common Error: Requesting more than 1 syringe per week without justification Fix: Standard quantity is 4 syringes per 28 days; document any dose modifications due to platelet monitoring

5. Wrong Benefit Category

Common Error: Submitting to pharmacy benefit when plan requires medical benefit processing Fix: Confirm benefit pathway before submission - most Cigna plans use medical benefit with J3490

Verification with Cigna Resources

Before submitting your Tegsedi prior authorization, verify coding requirements through these Cigna channels:

Electronic Verification Tools

Phone Verification

  • Provider line: 1-800-882-4462
  • Questions to ask:
    • "Is Tegsedi (NDC 72126-0007-02) processed under medical or pharmacy benefit?"
    • "What HCPCS code should I use for J3490 billing?"
    • "Are there specific quantity limits for weekly dosing?"

Policy Documentation

Check your specific Cigna plan's medical policy for:

  • Required diagnosis codes (should include E85.1)
  • Prior authorization criteria
  • Quantity limits and dosing restrictions
  • Required laboratory monitoring

Quick Audit Checklist

Before submitting your Tegsedi prior authorization to Cigna, review this checklist:

□ Diagnosis Coding

  • E85.1 documented in medical record
  • TTR genetic testing results attached
  • Neuropathy staging assessment included

□ Product Coding

  • Correct NDC: 72126-0007-02
  • Appropriate HCPCS: J3490 or C9399
  • Accurate units: 1 per syringe/week

□ Clinical Documentation

  • Recent platelet count ≥100 × 10⁹/L
  • Baseline renal function tests
  • Neurologist consultation notes
  • REMS enrollment confirmation

□ Quantity and Dosing

  • Weekly dosing: 284 mg subcutaneous
  • Quantity aligns with 4 syringes per 28 days
  • Any dose modifications documented

□ Submission Pathway

  • Confirmed medical vs. pharmacy benefit
  • Using correct electronic portal
  • Prescriber NPI and contact information included

Appeals Playbook for Florida

If Cigna denies your properly coded Tegsedi request, Florida residents have specific appeal rights:

Internal Appeal Process

  • Deadline: 180 days from denial notice
  • Timeline: Cigna must respond within 30 days (prospective) or 60 days (retrospective)
  • Expedited option: Available when delay threatens health; decided within 72 hours

Required Documentation for Appeal

  • Copy of original denial letter
  • Updated medical necessity letter addressing each denial reason
  • Additional clinical evidence (disease progression, failed alternatives)
  • Relevant medical literature supporting Tegsedi use

External Review (Florida)

  • When available: After exhausting internal appeals
  • Deadline: 4 months from final internal denial
  • Process: File through Florida Department of Financial Services
  • Cost: No charge to consumer
  • Decision: Binding on Cigna if favorable

Navigating insurance coverage for rare disease treatments like Tegsedi requires precision in coding and documentation. Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals by analyzing denial letters, plan policies, and clinical notes to identify the specific denial basis and draft point-by-point rebuttals aligned to each plan's requirements.

FAQ: Common Coding Questions

Q: Does Tegsedi require a specific J-code for Cigna billing? A: No, Tegsedi uses unclassified code J3490 (or C9399 for hospital outpatient). Always specify "Tegsedi (inotersen) 284 mg/1.5 mL" in the description.

Q: What ICD-10 code should I use for hATTR polyneuropathy? A: Use E85.1 (Neuropathic heredofamilial amyloidosis) as the primary diagnosis code, supported by genetic testing documentation.

Q: How do I calculate billing units for weekly Tegsedi dosing? A: Standard dosing is 1 syringe (284 mg) weekly = 1 unit per week. For 28-day supplies, bill 4 units.

Q: Is Tegsedi processed under medical or pharmacy benefit with Cigna? A: Most Cigna plans process Tegsedi under the medical benefit using HCPCS codes, even though it's self-administered. Verify with your specific plan.

Q: What documentation is required for REMS compliance? A: Include confirmation of patient, prescriber, and pharmacy enrollment in the Tegsedi REMS program, plus baseline and ongoing platelet/renal monitoring.

Q: How long does Cigna prior authorization take in Florida? A: Standard PA decisions within 2-3 business days; expedited reviews within 24 hours for urgent cases.

Q: Can I appeal if Cigna denies due to coding errors? A: Yes, you can resubmit with corrected coding or file an internal appeal within 180 days, addressing the specific coding issues cited in the denial.

Q: What quantity limits apply to Tegsedi with Cigna? A: Typical limit is 4 syringes per 28 days (weekly dosing). Higher quantities require justification for dose modifications due to monitoring requirements.

Sources & Further Reading

Medical Disclaimer: This guide provides general information about insurance coding and coverage processes. It is not medical advice. Always consult with your healthcare provider about treatment decisions and work with qualified billing professionals for specific coding questions. Coverage policies vary by plan and change frequently - verify current requirements with your insurer.

For additional support with complex prior authorizations and appeals, Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into successful approvals through evidence-backed appeal strategies tailored to each payer's specific requirements.

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