Get Crysvita (burosumab) Covered by Cigna in Illinois: Complete Prior Authorization and Appeals Guide
Answer Box: Getting Crysvita Covered by Cigna in Illinois
Eligibility: Crysvita (burosumab) requires prior authorization from Cigna for X-linked hypophosphatemia (XLH) or tumor-induced osteomalacia (TIO). Fastest path: Have your specialist submit the Cigna Crysvita CCRD Prior Authorization Form with genetic testing (XLH) or tumor documentation (TIO), baseline fasting serum phosphorus below normal, and specialist attestation. First step today: Contact your endocrinologist to request the PA form and gather required lab results. If denied, Illinois law provides a 30-day window for binding external review after internal appeals.
Table of Contents
- Coverage Requirements at a Glance
- Step-by-Step: Fastest Path to Approval
- Medical Coding That Supports Your Case
- Common Denial Reasons & How to Fix Them
- Illinois Appeals Process
- Costs & Patient Assistance Options
- When to Contact Illinois Regulators
- Frequently Asked Questions
Coverage Requirements at a Glance
| Requirement | What It Means | Where to Find It |
|---|---|---|
| Prior Authorization | Required for all Crysvita requests | Cigna PA Form Library |
| Specialist Prescriber | Endocrinologist, nephrologist, or metabolic bone specialist | Cigna Coverage Policy |
| Baseline Labs | Fasting serum phosphorus below normal range | Same coverage policy |
| Age Requirements | ≥6 months (XLH), ≥2 years (TIO) | FDA Label requirements |
| Billing Code | HCPCS J0584 (medical benefit) | Medical claims processing |
| Illinois Appeal Deadline | 30 days for external review | Illinois Health Carrier External Review Act |
Step-by-Step: Fastest Path to Approval
1. Confirm Your Diagnosis and Gather Documentation
Who: Your specialist (endocrinologist/nephrologist)
Timeline: 1-2 weeks
Documents needed:
- For XLH: PHEX genetic testing or elevated FGF23 level
- For TIO: Tumor imaging/pathology showing unresectable phosphaturic mesenchymal tumor
- Baseline fasting serum phosphorus (below normal range)
- Clinical notes documenting bone pain, fractures, or growth issues
2. Submit Cigna Prior Authorization Request
Who: Your prescriber's office
How: Cigna Crysvita CCRD Prior Authorization Form via fax or CoverMyMeds
Timeline: Cigna has 72 hours for standard review, 24 hours for expedited
Key requirement: Answer "Yes" to specialist question and attach all supporting documentation
3. Request Expedited Review if Appropriate
When: If bone pain is severe, fractures are healing poorly, or child's growth is significantly impacted
How: Mark "expedited" on PA form and provide clinical justification
Timeline: 24-hour decision required by Illinois law
4. Track Your Request
How: Call Cigna member services or check online portal
What to ask: "What's the status of my Crysvita prior authorization request?"
Follow-up: If no response within stated timeframe, escalate to Illinois Department of Insurance
Medical Coding That Supports Your Case
ICD-10 Codes for Proper Documentation
X-linked Hypophosphatemia (XLH):
- E83.31 - Familial hypophosphatemia (primary code)
- M83.8 - Other adult osteomalacia (if applicable)
- M84.30x-M84.38x - Stress fractures by site
Tumor-Induced Osteomalacia (TIO):
- E83.39 - Other disorders of phosphorus metabolism
- M83.8 - Other adult osteomalacia
- D48.0 - Neoplasm of uncertain behavior of bone and articular cartilage
HCPCS Billing and Units
- Code: J0584 (Injection, burosumab-twza, 1 mg)
- Units: 1 unit = 1 mg administered
- Example: 36 kg adult with XLH = 36 mg dose = 36 billing units
- Maximum: 90 mg (90 units) for XLH; 180 mg (180 units) for TIO
Tip: Crysvita is billed as a medical benefit using J0584, not through pharmacy benefit with NDC codes.
Clinician Corner: Medical Necessity Documentation
When preparing your Crysvita prior authorization, ensure your specialist includes:
Essential Clinical Elements:
- Problem statement: "Patient has confirmed [XLH/TIO] with FGF23-mediated hypophosphatemia"
- Diagnostic confirmation: Attach PHEX mutation report or elevated FGF23 lab
- Baseline measurements: Fasting serum phosphorus below age-adjusted normal
- Prior therapy history: Document conventional therapy trials (oral phosphate + calcitriol) and failures/intolerances
- Clinical impact: Bone pain scores, fracture history, mobility limitations, growth velocity (pediatric)
- Treatment goals: Target phosphorus normalization, pain reduction, fracture healing
Supporting Guidelines:
- FDA Crysvita Prescribing Information
- Endocrine Society Clinical Practice Guidelines on hypophosphatemia
- Cigna's own coverage criteria requiring specialist management
Common Denial Reasons & How to Fix Them
| Denial Reason | Solution | Documentation Needed |
|---|---|---|
| "Missing genetic confirmation" | Provide PHEX mutation report or elevated FGF23 | Lab report with reference ranges |
| "Step therapy not completed" | Document prior phosphate/calcitriol failure | Medication history, adverse effects |
| "Not prescribed by specialist" | Ensure endocrinologist/nephrologist submits | Provider credentials on letterhead |
| "Baseline phosphorus not documented" | Submit fasting serum phosphorus lab | Lab dated before any burosumab |
| "Age criteria not met" | Confirm patient ≥6 months (XLH) or ≥2 years (TIO) | Birth certificate, medical records |
Illinois Appeals Process
Internal Appeals with Cigna
Deadline: 180 days from denial
Timeline: 15 business days for standard, 24 hours for expedited
How to file: Written appeal with supporting documentation
What to include:
- Copy of denial letter
- Updated clinical notes
- Peer-reviewed studies supporting Crysvita use
- Patient impact statement
External Review (Illinois-Specific Rights)
Deadline: 30 days from Cigna's final internal denial
Timeline: 5 business days for decision
Cost: Free to patient
Process: Independent physician review, binding on Cigna
How to request:
- Contact Illinois Department of Insurance: (877) 527-9431
- Complete external review application
- Submit all medical records and denial correspondence
Important: Illinois has a shorter external review deadline (30 days) than many states. Don't delay after receiving Cigna's final denial.
Costs & Patient Assistance Options
Manufacturer Support:
- Crysvita Complete patient support program
- Financial assistance for eligible patients
- Prior authorization support services
Foundation Grants:
- National Organization for Rare Disorders (NORD)
- Patient Access Network Foundation
- HealthWell Foundation (verify current Crysvita coverage)
Average Costs (verify with current pricing):
- 10 mg/mL vial: ~$4,451
- 20 mg/mL vial: ~$8,903
- 30 mg/mL vial: ~$13,354
When dealing with complex prior authorization cases like Crysvita, having expert support can make the difference between approval and denial. Counterforce Health specializes in turning insurance denials into evidence-backed appeals, helping patients and clinicians navigate the prior authorization process more effectively. Their platform identifies specific denial reasons and crafts targeted responses aligned to each payer's requirements.
When to Contact Illinois Regulators
Contact the Illinois Department of Insurance if:
- Cigna doesn't respond within required timeframes
- You need help filing an external review
- You believe Cigna is violating Illinois insurance law
Contact Information:
- Phone: (877) 527-9431
- Office of Consumer Health Insurance (OCHI)
- Illinois DOI Website
Illinois Attorney General Health Care Bureau:
- Phone: (877) 305-5145
- Can intervene informally with insurers
- Helpful for complex appeal cases
Frequently Asked Questions
Q: How long does Cigna prior authorization take for Crysvita in Illinois?
A: 72 hours for standard requests, 24 hours for expedited. Illinois law requires these timelines be met.
Q: What if Crysvita is non-formulary on my Cigna plan?
A: Request a formulary exception along with your prior authorization. Illinois protects against step therapy requirements when your doctor certifies medical necessity.
Q: Can I get an expedited appeal if Cigna denies my request?
A: Yes, if delay would "seriously jeopardize your life, health, or ability to regain maximum function." Both internal and external reviews can be expedited.
Q: Does step therapy apply if I failed conventional therapy in another state?
A: Document all prior therapies regardless of where tried. Illinois law allows step therapy override when your physician certifies previous treatments were ineffective or detrimental.
Q: What happens if the external reviewer approves my Crysvita coverage?
A: The decision is binding on Cigna. They must provide coverage according to the reviewer's determination.
Q: How do I know if my Cigna plan covers Crysvita?
A: Check your plan's formulary or call member services. Even if not listed, you can request a formulary exception with medical justification.
For additional support with your Crysvita prior authorization, Counterforce Health offers specialized assistance in preparing evidence-backed appeals and navigating payer-specific requirements.
Sources & Further Reading
- Cigna Crysvita Coverage Policy
- Cigna Prior Authorization Forms
- Illinois Department of Insurance Consumer Assistance
- FDA Crysvita Prescribing Information
- Illinois Health Carrier External Review Act
- Crysvita Complete Patient Support
Disclaimer: This information is for educational purposes only and does not constitute medical advice. Always consult with your healthcare provider regarding treatment decisions. Insurance coverage policies change frequently; verify current requirements with your specific plan. For personalized assistance with Illinois insurance issues, contact the Illinois Department of Insurance at (877) 527-9431.
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