By Counterforce Health Team in iLink® (corneal cross-linking system) —

Get iLink® Corneal Cross-Linking Covered by Cigna in North Carolina: Forms, Appeals & Smart NC Guide

Quick Answer: Getting iLink® Covered by Cigna in North Carolina

Cigna covers iLink® corneal cross-linking for progressive keratoconus when medical necessity criteria are met. Your fastest path: have your ophthalmologist submit prior authorization through CoverMyMeds with documentation of disease progression (serial topography, worsening vision). If denied, North Carolina residents can request a Smart NC external review within 120 days. Start today: Gather your corneal topography results, visual acuity records, and insurance card.

Table of Contents

  1. Coverage Overview: What Cigna Covers
  2. Prior Authorization Forms & Submission
  3. Medical Necessity Requirements
  4. Appeals Process: Internal & External
  5. Smart NC External Review
  6. Common Denial Reasons & Solutions
  7. Support Resources & Contact Information
  8. FAQ

Coverage Overview: What Cigna Covers

Cigna considers epithelium-off corneal cross-linking using FDA-approved systems (like iLink®) medically necessary for:

  • Progressive keratoconus
  • Corneal ectasia following refractive surgery (LASIK/PRK)

The procedure uses CPT code 0402T and HCPCS code J3490 for the riboflavin solutions. Coverage is typically once per lifetime per eye, as repeat procedures aren't routinely supported by evidence.

Important: Only the FDA-approved epithelium-off technique is covered. Epithelium-on (transepithelial) cross-linking is considered experimental and not covered by Cigna.

Coverage at a Glance

Requirement What It Means Where to Find It
Prior Authorization Required before procedure Cigna Provider Portal
Progressive Disease Documented worsening over time Serial topography, refraction records
FDA-Approved System Must use iLink® or equivalent Glaukos iLink® Information
One-Time Treatment Coverage once per eye per lifetime Cigna medical policy

Prior Authorization Forms & Submission

Electronic Submission (Preferred)

Cigna strongly recommends electronic submission through:

Alternative Submission Methods

If electronic submission isn't possible:

  • Phone: 1-800-882-4462
  • Fax: 1-866-949-4846 (prior authorization)
  • Medical Precertification Fax: 1-866-873-8279
Tip: Electronic submissions typically process faster and provide automatic confirmation of receipt.

Required Documentation

Your ophthalmologist must include:

  • Completed prior authorization form
  • Patient demographics and Cigna ID
  • Diagnosis code for keratoconus
  • Clinical records supporting progressive disease
  • Previous treatment history
  • Justification for medical necessity

Medical Necessity Requirements

To meet Cigna's medical necessity criteria, documentation must show progressive keratoconus through:

Objective Progression Indicators

  • Increasing corneal curvature (steepening keratometry readings)
  • Worsening best-corrected visual acuity
  • Increasing astigmatism or myopia on refraction
  • Corneal thinning or other measurable changes over time

Clinician Corner: Medical Necessity Letter Checklist

When preparing your medical necessity letter, include:

  • Clear diagnosis with ICD-10 code
  • Serial topography showing progression
  • Visual acuity measurements over time
  • Previous treatments attempted (if any)
  • Clinical rationale for cross-linking
  • Reference to FDA approval and clinical guidelines

Key Guidelines to Reference:

  • FDA labeling for Photrexa/KXL system
  • American Academy of Ophthalmology guidelines
  • Cornea Society recommendations

Appeals Process: Internal & External

If your initial prior authorization is denied, North Carolina residents have multiple appeal options.

Cigna Internal Appeals

First-Level Internal Appeal

  • Timeline: Must be filed within 180 days of denial
  • Process: Submit additional clinical documentation
  • Decision timeframe: Up to 30 days (15 days for urgent requests)

Second-Level Internal Appeal

  • Available if first-level appeal is denied
  • Same timeline and submission process
  • Final internal decision from Cigna

Expedited Appeals

For urgent cases where vision is at risk:

  • Timeline: 24-72 hours for decision
  • How to request: Mark form as urgent and call Cigna
  • Criteria: Imminent threat to vision or eye health
Note: You must typically exhaust internal appeals before requesting external review, unless you qualify for expedited processing.

Smart NC External Review

North Carolina's Smart NC program provides free, independent review of insurance denials through the NC Department of Insurance.

Eligibility Requirements

  • Must be within 120 days of final Cigna denial
  • Denial must be based on medical necessity or experimental treatment determination
  • Insurance plan must be state-regulated (not self-funded employer plans)
  • Internal appeals must be exhausted (with exceptions for expedited cases)

How to Request External Review

Step 1: Gather Documents

  • Final denial letter from Cigna
  • Medical records and test results
  • Corneal topography reports
  • Visual acuity documentation
  • Insurance card copy

Step 2: Complete Application

  • Download North Carolina External Review Request Form
  • Describe why you disagree with the denial
  • Include all supporting documentation

Step 3: Submit to Smart NC

  • Mail: Health Insurance Smart NC, 1201 Mail Service Center, Raleigh, NC 27699-1201
  • Phone for assistance: 855-408-1212

External Review Process

  1. Smart NC reviews application for completeness and eligibility
  2. Independent Review Organization (IRO) assigned on rotating basis
  3. You may submit additional information within 7 days of acceptance
  4. IRO issues binding decision within 45 days (72 hours for expedited)
  5. If approved, Cigna must provide coverage within 3 business days
Important: The IRO's decision is binding on Cigna. If they approve coverage, your insurer must pay for the procedure.

Counterforce Health specializes in helping patients navigate complex insurance appeals like these, turning denial letters into targeted, evidence-backed appeals that align with payer policies and clinical guidelines.

Common Denial Reasons & Solutions

Denial Reason How to Overturn Required Documentation
Insufficient progression evidence Submit serial topography Corneal maps showing steepening over 6-12 months
Non-FDA approved system Confirm iLink® usage Provider attestation of FDA-approved equipment
Experimental/investigational Cite FDA approval FDA labeling, clinical studies, payer policy
Prior therapy required Document contraindications Medical records showing why alternatives unsuitable
Non-participating provider Find in-network specialist Cigna provider directory search

Scripts for Common Situations

Calling Cigna About Denial: "I'm calling about prior authorization denial for corneal cross-linking, reference number [X]. My ophthalmologist documented progressive keratoconus with worsening topography over [timeframe]. Can you explain what additional clinical information is needed for approval?"

Requesting Peer-to-Peer Review: "We'd like to request a peer-to-peer review for the denied corneal cross-linking authorization. The treating ophthalmologist is available [days/times] to discuss the medical necessity with your medical director."

Support Resources & Contact Information

Cigna Contacts

  • Member Services: 1-800-244-6224
  • Provider Customer Service: 1-800-882-4462
  • Prior Authorization: 1-866-949-4846 (fax)
  • Cigna Specialty Pharmacy: 1-800-735-1459

North Carolina Resources

  • Smart NC (External Review): 855-408-1212
  • NC Department of Insurance: ncdoi.gov
  • Consumer Assistance: Free help with forms and appeals process

Manufacturer Support

When dealing with complex insurance denials, Counterforce Health helps patients and clinicians build compelling appeals by identifying the specific denial basis and crafting point-by-point rebuttals using the right clinical evidence and payer-specific workflows.

FAQ

How long does Cigna prior authorization take in North Carolina? Standard prior authorization typically takes up to 5 business days. Urgent requests (when vision is threatened) are processed within 24-72 hours.

What if iLink® is considered non-formulary? iLink® cross-linking is a medical procedure, not a formulary drug. However, the riboflavin solutions may require separate approval. Work with your provider to ensure all components are authorized.

Can I request an expedited appeal? Yes, if there's imminent risk to your vision or eye health. Mark your appeal as urgent and call Cigna to expedite processing.

What happens if Smart NC external review is denied? The IRO decision is final for the administrative process. You may still have legal rights, but the insurance appeal process is complete.

Does step therapy apply to corneal cross-linking? Generally no, as cross-linking is the only FDA-approved treatment to halt keratoconus progression. However, Cigna may require documentation that the condition is progressive rather than stable.

How much does the procedure cost without insurance? iLink® corneal cross-linking typically costs $2,500-$4,000 per eye when paid out-of-pocket, though prices vary by provider and geographic location.

Can I appeal if I have an employer self-funded plan? Self-funded employer plans aren't subject to North Carolina's external review process. Check your plan documents for internal appeal rights, or contact the Department of Labor for ERISA-related guidance.

What documentation should I keep during the appeals process? Keep copies of all correspondence, denial letters, medical records submitted, phone call logs with reference numbers, and certified mail receipts for any mailed appeals.

Medical Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Always consult with your healthcare provider and insurance company for guidance specific to your situation.

Sources & Further Reading:

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