By Counterforce Health Team in Oxervate (cenegermin) —

Get Oxervate (Cenegermin) Covered by Cigna in New York: Prior Authorization Guide, Appeals Process & Alternative Treatments

Answer Box: Getting Oxervate (Cenegermin) Covered by Cigna in New York

Oxervate (cenegermin) requires prior authorization from Cigna and typically involves step therapy with alternatives like preservative-free artificial tears and autologous serum drops first. If denied, you have 180 days for internal appeals and can request external review through New York's Department of Financial Services within 4 months. First step today: Have your eye doctor document your neurotrophic keratitis diagnosis (stage 2 or 3) and prior treatment failures, then submit Cigna's PA request through their provider portal or CoverMyMeds.

Table of Contents

When Alternatives Make Sense

Before pursuing Oxervate (cenegermin), it's important to understand when starting with alternatives might be appropriate. Cigna requires step therapy for most neurotrophic keratitis treatments, meaning you'll typically need to try and document failure with conventional therapies first.

Alternatives make clinical sense when:

  • You have early-stage neurotrophic keratitis that might respond to supportive care
  • The diagnosis is still being confirmed through corneal sensitivity testing
  • You're waiting for specialty consultation or additional imaging
  • Cost considerations are significant (Oxervate courses commonly cost in the low six figures)

However, don't delay appropriate treatment. Stage 2 and 3 neurotrophic keratitis can progress rapidly, and early intervention with nerve growth factor therapy has better outcomes than delayed treatment.

Typical Alternatives to Oxervate

First-Line Supportive Therapies

Preservative-Free Artificial Tears

  • Most commonly covered by Cigna without prior authorization
  • Examples: Refresh Plus, Systane Ultra, TheraTears
  • Used every 1-2 hours for surface lubrication
  • Limited effectiveness for persistent epithelial defects but required documentation

Ophthalmic Lubricating Ointments

  • Typically covered; used at bedtime
  • Examples: Refresh PM, GenTeal Severe
  • Provides longer-lasting protection but can blur vision

Second-Line Therapies

Autologous Serum Eye Drops

  • May require prior authorization depending on your Cigna plan
  • Contains natural growth factors that support healing
  • Requires blood draw and compounding pharmacy
  • More effective than artificial tears alone for persistent defects

Bandage Contact Lenses

  • Usually covered as durable medical equipment
  • Provides mechanical protection and promotes healing environment
  • Risk of infection requires careful monitoring
  • Often used in combination with drops

Advanced Alternatives

Amniotic Membrane Transplantation

  • Covered as a surgical procedure by most Cigna plans
  • Contains natural growth factors and anti-inflammatory properties
  • More invasive than drops but can be effective for severe cases
  • May be considered before or instead of Oxervate

Coverage at a Glance: Cigna Requirements

Requirement What It Means Where to Find It Source
Prior Authorization Required for Oxervate Cigna Provider Portal Cigna PA Policy
Step Therapy Try alternatives first Plan formulary document Express Scripts Formulary
Diagnosis Code Stage 2/3 neurotrophic keratitis ICD-10: H16.23 (verify with provider) FDA Label
Appeal Deadline 180 days for internal Member handbook Cigna Appeals Process
External Review 4 months after final denial NY DFS website NY External Appeals

Step-by-Step: Fastest Path to Approval

1. Confirm Your Diagnosis (Patient + Doctor)

Who does it: Your ophthalmologist
Document needed: Clinical notes confirming stage 2 or 3 neurotrophic keratitis with corneal sensitivity testing
Timeline: Same day as appointment
Source: FDA prescribing information

2. Document Prior Treatment Failures (Doctor)

Who does it: Your eye doctor's office
Document needed: Records showing adequate trials of artificial tears, serum drops, or other alternatives with dates and outcomes
Timeline: 1-2 business days to compile
Source: Cigna PA requirements

3. Submit Prior Authorization Request (Doctor's Office)

Who does it: Prescribing physician or their staff
How to submit: CoverMyMeds portal or Cigna provider portal
Timeline: 72 hours for standard review, 24 hours for expedited
Required attachments: Clinical notes, prior therapy documentation, treatment plan

4. Follow Up on PA Status (Patient + Doctor)

Who does it: You can check member portal; doctor's office should also monitor
Timeline: Check after 3 business days
Next step: If approved, coordinate with specialty pharmacy; if denied, proceed to appeals

5. Request Peer-to-Peer Review if Initially Denied (Doctor)

Who does it: Your ophthalmologist
How: Call Cigna's provider services line to request physician-to-physician discussion
Timeline: Usually scheduled within 1-2 business days
Benefit: Often resolves clinical questions that led to initial denial

Exception Strategy: When to Push for Oxervate

Push for direct Oxervate approval when you have:

Absolute Contraindications to Alternatives

  • Documented allergy to preservatives in artificial tears
  • Active ocular infection preventing contact lens use
  • Prior complications from serum drops or amniotic membrane

Rapid Disease Progression

  • Corneal thinning or impending perforation
  • Failure of alternatives within 2-4 weeks (rather than the typical 8-12 week trial)
  • Progressive epithelial defect despite maximal supportive care

Prior Oxervate Success

  • Previous response to cenegermin for the same condition
  • Well-documented treatment history from another insurer
Tip: When requesting expedited review, emphasize risk of corneal perforation or vision loss. New York allows 24-hour decisions for urgent drug appeals that pose serious health risks.

Switching Logistics and Coordination

Working with Your Eye Doctor

Your ophthalmologist will need to:

  • Submit detailed clinical notes supporting medical necessity
  • Provide comparison photos or measurements when possible
  • Coordinate with Cigna's medical director if peer-to-peer review is requested
  • Monitor your response to document effectiveness

Pharmacy Coordination

Oxervate requires specialty pharmacy handling:

  • Cigna typically uses Accredo for specialty medications
  • The medication requires refrigeration and has a short shelf life
  • Your doctor will need to send the prescription to the designated specialty pharmacy
  • Expect 3-5 business days for delivery after approval

Patient Responsibilities

  • Keep all appointment dates for monitoring
  • Document any side effects or lack of improvement
  • Take photos of your eye if recommended by your doctor
  • Save all insurance correspondence and denial letters

Re-trying for Oxervate Later

If you start with alternatives and they don't work, switching back to cenegermin requires specific documentation:

Treatment Failure Criteria

  • Lack of complete corneal healing after adequate trial (typically 8-12 weeks)
  • Disease progression despite maximal alternative therapy
  • Development of complications like corneal ulceration

Required Documentation

  • Baseline and follow-up photos or measurements
  • Detailed notes about each alternative tried, duration, and specific outcomes
  • Objective measures like corneal staining patterns
  • Patient-reported symptoms and functional impact
From our advocates: We often see faster approvals when patients keep a simple diary of symptoms and visual function during alternative treatments. Even basic notes like "still having pain and tearing after 6 weeks of serum drops" can strengthen the medical necessity case.

Appeals Playbook for Cigna in New York

Internal Appeals (First Level)

Timeline: Must file within 180 days of denial
How to file: Cigna member portal or written request
Decision deadline: 30 days for standard, 72 hours for expedited
What to include: Original denial letter, additional clinical documentation, peer-reviewed literature supporting treatment

Internal Appeals (Second Level)

When: After first-level denial
Timeline: 60 days from first-level decision
Review: Independent medical professional not involved in original decision
Outcome: Final internal determination from Cigna

External Review Through New York DFS

Eligibility: After final internal denial for "not medically necessary" determinations
Timeline: 4 months to file after final internal denial
Cost: $25 (waived for Medicaid or financial hardship)
Decision: Binding on Cigna if overturned

How to file: Submit external appeal application with:

  • Cigna's final denial letter
  • All medical records
  • Supporting literature
  • Provider letter of medical necessity

For assistance with external appeals, contact Community Health Advocates at 888-614-5400.

Common Denial Reasons & How to Fix Them

Denial Reason How to Overturn Documents Needed
"Not medically necessary" Provide evidence-based literature showing Oxervate effectiveness for your specific condition Peer-reviewed studies, FDA label, specialty guidelines
"Alternatives not tried" Document adequate trials and failures of step therapy options Treatment logs, clinical notes, photos showing lack of improvement
"Experimental/investigational" Cite FDA approval and established use in neurotrophic keratitis FDA approval letter, published treatment protocols
"Diagnosis not confirmed" Provide corneal sensitivity testing and specialist confirmation Ophthalmology consultation notes, diagnostic test results

FAQ

How long does Cigna prior authorization take in New York?
Standard PA decisions are made within 72 hours. Expedited requests for urgent medical needs are decided within 24 hours.

What if Oxervate is non-formulary on my Cigna plan?
You can request a formulary exception with clinical justification. Non-formulary drugs often require higher cost-sharing but can still be covered.

Can I request an expedited appeal if my condition is worsening?
Yes. If delay poses serious risk to your health or vision, both Cigna and New York's external review process offer expedited timelines.

Does step therapy apply if I failed alternatives with a previous insurer?
Documentation of prior failures with other insurers can sometimes satisfy step therapy requirements, but Cigna may still require a brief trial to confirm.

What's the success rate for external appeals in New York?
New York's external appeal process has historically overturned 40-50% of denials, with higher success rates when strong medical literature supports the treatment.

How much does Oxervate cost without insurance?
An 8-week course commonly costs in the low six figures. Manufacturer support programs may help with copays for eligible patients.

Getting help with complex insurance denials and appeals can be overwhelming. Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into targeted, evidence-backed appeals. The platform analyzes denial letters and plan policies, then drafts point-by-point rebuttals using the right medical evidence and payer-specific requirements. For complex cases like rare ophthalmologic conditions, having expert support can significantly improve your chances of approval.

If you're struggling with a Cigna denial for Oxervate or other specialty treatments, don't give up. New York's strong consumer protection laws and external review process give you multiple avenues to fight unfair denials. The key is thorough documentation, understanding your rights, and knowing when to escalate to Counterforce Health or other advocacy resources.

Sources & Further Reading

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. For help navigating insurance appeals in New York, contact the Department of Financial Services at (800) 400-8882.

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