By Counterforce Health Team in Crysvita (burosumab) —

Get Crysvita (Burosumab) Covered by Cigna in Virginia: Complete Guide to Prior Authorization, Appeals, and State External Review

Answer Box: Getting Crysvita (Burosumab) Covered by Cigna in Virginia

Cigna requires prior authorization for Crysvita (burosumab) with genetic confirmation of X-linked hypophosphatemia (XLH), clinical documentation, and serum phosphorus monitoring. The fastest path to approval involves three steps: (1) Complete genetic testing for XLH through the free Kyowa Kirin/Invitae program, (2) Have your endocrinologist submit a comprehensive medical necessity letter citing the 2025 International Working Group guidelines, and (3) If denied, file an internal appeal within 180 days, followed by Virginia's external review process through the State Corporation Commission if needed.

Table of Contents

Coverage Requirements at a Glance

Requirement What It Means Where to Find It Source
Prior Authorization Required for all Crysvita prescriptions Cigna formulary Cigna Member Portal
Genetic Testing PHEX mutation or XLH gene panel confirmation Free testing available Invitae XLH Testing
Clinical Documentation ≥2 XLH symptoms or prior clinical diagnosis Provider notes required XLH Link HCP
Lab Monitoring Fasting serum phosphorus (below normal for age) Baseline and ongoing Ultracare Support
Specialty Pharmacy Dispensed through Accredo Cigna's preferred specialty pharmacy Cigna Specialty Pharmacy

Step-by-Step: Fastest Path to Approval

1. Confirm Your XLH Diagnosis (Patient + Provider)

Timeline: 2-4 weeks
Action: Order genetic testing through the free Kyowa Kirin/Invitae program. Your doctor completes the provider requisition form, and you provide a blood or saliva sample.
Submit: Results automatically sent to your provider
Source: Invitae Sponsored Testing

2. Gather Clinical Evidence (Provider)

Timeline: 1-2 weeks
Action: Document clinical symptoms (bone pain, fractures, dental issues, short stature), collect baseline labs (serum phosphorus, FGF23, vitamin D), and obtain relevant imaging.
Submit: Compile in medical necessity letter
Source: XLH Diagnostic Criteria

3. Submit Prior Authorization (Provider)

Timeline: 5-10 business days for decision
Action: Provider submits PA request through Cigna portal or Express Scripts with complete documentation package.
Submit: Via Cigna provider portal or fax
Source: Cigna PA Process

4. Request Peer-to-Peer if Denied (Provider)

Timeline: 24-48 hours to schedule
Action: Provider calls Cigna to request peer-to-peer review with medical director.
Submit: Phone request to Cigna utilization management
Source: Contact number on denial letter

5. File Internal Appeal if Still Denied (Patient/Provider)

Timeline: 180 days to file, 30-60 days for decision
Action: Submit written appeal with additional clinical evidence and guideline citations.
Submit: Cigna appeals department (address on denial notice)
Source: Appeal rights outlined in denial letter

6. Pursue External Review Through Virginia (Patient)

Timeline: 120 days to file, 45 days for decision
Action: File external review request with Virginia State Corporation Commission Bureau of Insurance.
Submit: Written request to Virginia SCC
Source: Virginia External Review Process

Clinician Corner: Medical Necessity Letter

For Endocrinologists and Prescribing Physicians

Your medical necessity letter should include these key elements to maximize approval chances:

Essential Components:

  • Diagnosis confirmation: Genetic testing results (PHEX mutation) or clinical diagnosis based on ≥2 characteristic symptoms
  • Biochemical evidence: Low fasting serum phosphorus, elevated/normal FGF23, low/normal 1,25(OH)2 vitamin D
  • Clinical presentation: Document bone pain, fractures/pseudofractures, dental complications, functional limitations
  • Treatment rationale: Cite 2025 International Working Group guidelines recommending burosumab as first-line therapy for adults with active fractures
  • Conventional therapy status: Document failure, intolerance, or contraindications to phosphate/active vitamin D
  • Expected outcomes: Improved bone healing, reduced pain, better function based on clinical trial data

Key Guidelines to Reference:

Common Denial Reasons & How to Fix Them

Denial Reason How to Overturn Required Documentation
Lack of genetic confirmation Submit PHEX mutation results Free genetic testing
Insufficient clinical evidence Document ≥2 XLH symptoms Detailed symptom history, imaging
Missing lab monitoring plan Provide phosphorus monitoring protocol Lab schedule, target ranges
Use with contraindicated meds Confirm no concurrent phosphate/vitamin D Current medication list
Non-formulary status Request formulary exception Clinical superiority evidence
Quantity limits exceeded Justify weight-based dosing Patient weight, dosing calculations

Appeals Playbook for Cigna in Virginia

Internal Appeals Process

First Level: Submit written appeal within 180 days of denial

  • Timeline: 30 days for standard review, 72 hours for urgent
  • Submit to: Address provided on denial letter
  • Required: Original denial letter, additional clinical evidence, prescriber letter

Second Level: Available if first appeal denied

  • Timeline: Additional 30 days
  • Process: Automatic review by different medical reviewer

Virginia External Review

Eligibility: After completing internal appeals or if insurer fails to respond

  • Timeline: 120 days to file from final internal denial
  • Process: Independent medical review by qualified specialists
  • Decision: Binding on insurer if overturned
  • Cost: Free to patients

How to File:

  1. Contact Virginia SCC Bureau of Insurance at 1-877-310-6560
  2. Complete external review request form
  3. Submit with denial letters and medical records
  4. SCC assigns to Independent Review Organization (IRO)

Source: Virginia Code § 38.2-3561

Scripts & Templates

Patient Phone Script for Cigna

"Hello, I'm calling about a prior authorization denial for Crysvita, generic name burosumab, for X-linked hypophosphatemia. My policy number is [X]. I'd like to understand the specific denial reasons and request information about the appeals process and peer-to-peer review options. Can you also confirm if this medication requires specialty pharmacy dispensing through Accredo?"

Peer-to-Peer Request Script for Providers

"I'm requesting a peer-to-peer review for my patient's Crysvita denial. The patient has genetically confirmed XLH with active pseudofractures and has failed conventional therapy. The 2025 International Working Group guidelines now recommend burosumab as first-line therapy for this indication. I'm available [specific time windows] for the review call."

Virginia State External Review Process

Virginia provides one of the most robust external review processes in the nation for specialty drug denials. Here's what makes it particularly valuable for Crysvita cases:

Key Advantages:

  • Independent medical specialists review your case
  • Decision is binding on Cigna if coverage is approved
  • No cost to patients
  • 45-day decision timeline
  • Strong track record for rare disease medication approvals

Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals. Our platform helps patients and providers navigate complex prior authorization requirements by analyzing denial letters, identifying specific denial criteria, and drafting comprehensive appeals that align with payer policies and clinical guidelines.

When to Use External Review:

  • After exhausting internal appeals
  • For urgent medical necessity denials (expedited 72-hour review available)
  • When you have strong clinical evidence supporting medical necessity

Contact Virginia SCC:

  • Phone: 1-877-310-6560
  • Online: Virginia State Corporation Commission website
  • Address: (verify current address when filing)

Costs & Patient Assistance

Crysvita Pricing: $4,000-$40,000+ per vial depending on strength and dosing requirements

Patient Assistance Options:

  • Kyowa Kirin Patient Assistance Program: Income-based free drug program
  • Crysvita Co-pay Card: May reduce out-of-pocket costs for commercially insured patients
  • HealthWell Foundation: Grants available for rare disease medications
  • National Organization for Rare Disorders (NORD): Patient assistance programs

Virginia-Specific Resources:

  • Virginia Medicaid covers Crysvita with prior authorization
  • State pharmaceutical assistance programs may be available for qualifying residents

For the most comprehensive support in navigating insurance approvals, Counterforce Health provides specialized expertise in rare disease medication appeals, helping patients get the coverage they need through evidence-based advocacy.

FAQ

How long does Cigna prior authorization take for Crysvita in Virginia? Standard PA decisions are made within 5-10 business days. Urgent requests may be expedited to 24-72 hours with proper clinical justification.

What if Crysvita is non-formulary on my Cigna plan? Request a formulary exception through your prescriber. Provide clinical evidence showing medical necessity and superiority over formulary alternatives.

Can I request an expedited appeal for Crysvita? Yes, if your physician certifies that delay could seriously jeopardize your health. Expedited reviews are decided within 72 hours.

Does step therapy apply to Crysvita? Many Cigna plans require trial of conventional therapy (phosphate supplements and active vitamin D) before approving Crysvita, unless contraindicated or previously failed.

What happens if Virginia external review approves my Crysvita coverage? Cigna must authorize coverage within 1-3 days of the IRO decision. The decision is legally binding on the insurer.

How much does genetic testing for XLH cost? The Kyowa Kirin/Invitae sponsored testing program provides genetic testing at no cost to patients or providers when ordered for potential Crysvita treatment.

Can I fill Crysvita at any pharmacy? No, Cigna typically requires specialty pharmacy dispensing through Accredo. Contact Accredo at 800-922-8279 to initiate the process once approved.

What if I'm currently on phosphate supplements? You must discontinue oral phosphate and active vitamin D supplements before starting Crysvita, as concurrent use is contraindicated and will result in denial.

From Our Advocates: We've seen many Virginia patients successfully obtain Crysvita coverage after initial denials by ensuring genetic testing was complete, providing comprehensive symptom documentation, and citing the latest clinical guidelines in their appeals. The key is persistence and thorough documentation—most approvals come after the first or second appeal when all clinical criteria are properly addressed.

Disclaimer: This guide provides educational information about insurance processes and should not be considered medical or legal advice. Always consult with your healthcare providers about treatment decisions and consider consulting with qualified professionals for complex insurance appeals. For official Virginia external review forms and current procedures, contact the Virginia State Corporation Commission Bureau of Insurance directly.

Sources & Further Reading:

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