By Counterforce Health Team in Photrexa (riboflavin ophthalmic solution) —

Get Photrexa (Riboflavin) Covered by Cigna in Washington: Complete Appeals Guide with Forms and Deadlines

Answer Box: Getting Photrexa Covered by Cigna in Washington

Cigna requires prior authorization for Photrexa (riboflavin ophthalmic solution) as part of corneal cross-linking for progressive keratoconus. To get approval:

  1. Submit PA electronically via CoverMyMeds or Cigna Provider Portal with documented progression evidence (Kmax increase ≥1.0 D, serial topography)
  2. If denied, file internal appeal within 180 days with comprehensive medical necessity documentation
  3. Request external review through Washington's IRO process if internal appeals fail—decisions are binding on Cigna

First step today: Gather serial corneal topography showing progression and coordinate with your ophthalmologist to submit the PA request electronically for fastest processing.

Table of Contents

Coverage Requirements at a Glance

Requirement What It Means Where to Find It Source
Prior Authorization PA required before treatment Cigna Provider Portal Cigna PA Requirements
Progressive Disease Documented Kmax increase ≥1.0 D Serial topography/tomography Clinical evidence
FDA-Approved Only Epithelium-off CXL with iLink system Treatment protocol FDA Labeling
ICD-10 Coding H18.621 (unstable keratoconus) Provider documentation Medical records
Appeal Deadline 180 days from denial Denial letter Cigna Appeals Process

Step-by-Step: Fastest Path to Approval

1. Document Disease Progression (Patient + Ophthalmologist)

Timeline: Before PA submission

  • Collect serial corneal topography showing Kmax increase ≥1.0 diopter
  • Document visual acuity decline or increasing astigmatism
  • Record failed contact lens management attempts

2. Submit Prior Authorization Electronically (Ophthalmologist)

Timeline: 3-5 business days for decision

  • Use CoverMyMeds or Cigna Provider Portal
  • Include ICD-10 code H18.621 for progressive keratoconus
  • Attach comprehensive clinical documentation

3. Track Authorization Status (Patient)

Timeline: Monitor daily

  • Check status via myCigna app or website
  • Contact provider if no response within 5 business days

4. Prepare for Potential Denial (Both)

Timeline: Within 24 hours of denial

  • Review denial letter for specific reasons
  • Begin gathering additional evidence for appeal

Common Denial Reasons & How to Fix Them

Denial Reason How to Overturn Required Documentation
"Experimental/Investigational" Emphasize FDA approval of iLink system FDA approval letter, clinical guidelines
"Not Medically Necessary" Provide progression evidence Serial topography, visual acuity charts
"Missing Documentation" Submit complete clinical records Chart notes, prior treatments, test results
"Non-Formulary Drug" Request formulary exception Medical necessity letter, peer-reviewed studies

Appeals Playbook for Cigna in Washington

Internal Appeals (First Level)

  • Deadline: 180 days from denial date
  • How to File: Written appeal to Cigna appeals department
  • Timeline: 60-day review period
  • Required: Original denial letter, clinical documentation, medical necessity letter

Internal Appeals (Second Level)

  • Automatic: If first appeal denied
  • Timeline: Additional 60 days
  • Enhanced Evidence: Peer-to-peer review, additional clinical studies

External Review (Washington IRO Process)

  • Eligibility: After exhausting internal appeals
  • How to Request: Through Washington Insurance Commissioner
  • Timeline: 30 days for standard review, 72 hours for expedited
  • Binding Decision: Cigna must comply if overturned
Note: Washington's external review process has strong consumer protections. The IRO can override Cigna's medical necessity standards if they're found unreasonable.

Medical Necessity Letter Essentials

Your ophthalmologist should include these key elements:

Patient-Specific Factors:

  • Diagnosis: Progressive keratoconus with ICD-10 code H18.621
  • Age and visual demands (school, work, driving)
  • Documentation of progression over time

Clinical Evidence:

  • Serial topography showing Kmax increase ≥1.0 D
  • Best-corrected visual acuity decline
  • Failed conservative management (contact lenses)

Treatment Rationale:

  • FDA approval of Photrexa with iLink system
  • Risk of continued progression without treatment
  • Potential need for corneal transplant if untreated

Supporting Literature:

  • American Academy of Ophthalmology guidelines
  • Peer-reviewed studies on CXL efficacy
  • FDA labeling information

When to Escalate to Washington State

Contact the Washington Insurance Commissioner at 1-800-562-6900 if:

  • Cigna fails to respond within required timelines
  • You believe the denial violates Washington insurance law
  • You need help navigating the external review process
  • You want to file a complaint about unfair claim practices

Washington has strong consumer protection laws and actively assists residents with insurance disputes.

FAQ: Photrexa Coverage in Washington

Q: How long does Cigna PA take in Washington? A: Electronic submissions typically receive decisions within 3-5 business days. Paper submissions may take up to 14 days.

Q: What if Photrexa is non-formulary on my plan? A: Request a formulary exception with medical necessity documentation. Cigna must provide a pathway for exceptions.

Q: Can I request an expedited appeal? A: Yes, if delay could seriously jeopardize your health or vision. Document the urgency clearly.

Q: Does step therapy apply to Photrexa? A: Generally no, as Photrexa is used for a specific FDA-approved indication with limited alternatives.

Q: What's the success rate for appeals in Washington? A: While specific rates aren't published, Washington's strong consumer protections and external review process provide good chances for overturning inappropriate denials.

Q: Can I use the IRO process for Medicare Advantage? A: Medicare Advantage has its own appeals process, but Washington residents can contact the Insurance Commissioner for guidance.

Patient Success Story

From our advocates: A 28-year-old teacher in Seattle initially received a Cigna denial for Photrexa, with the insurer citing "experimental" status. Her ophthalmologist submitted an appeal emphasizing FDA approval and included six months of topography showing clear progression. The peer-to-peer review was key—the treating physician directly explained to Cigna's medical director how the patient's vision was deteriorating despite contact lens management. The appeal was approved within 45 days, and the patient successfully underwent cross-linking at an in-network facility.

Getting Help with Your Appeal

Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals. Our platform analyzes denial letters and plan policies to identify the specific basis for denial—whether it's PA criteria, medical necessity, or non-formulary status—then drafts point-by-point rebuttals aligned to the plan's own rules.

For Photrexa appeals, we pull the right clinical evidence including FDA labeling, peer-reviewed studies on corneal cross-linking, and specialty ophthalmology guidelines. We help ensure your appeal includes all required clinical facts like diagnosis codes, progression documentation, and treatment goals while meeting Cigna's procedural requirements and Washington's appeal deadlines.

Checklist: What to Gather Before You Start

Insurance Information:

  • Cigna member ID card
  • Current formulary document
  • Summary of benefits

Medical Records:

  • Serial corneal topography (at least 2 visits)
  • Visual acuity measurements over time
  • Contact lens fitting records
  • Ophthalmologist's clinical notes

Prior Treatments:

  • Documentation of contact lens trials
  • Records of vision correction attempts
  • Any complications or failures

Support Documents:

  • Denial letter (if applicable)
  • Explanation of Benefits (EOB)
  • Prescription for Photrexa treatment

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage varies by plan and individual circumstances. Always consult with your healthcare provider and insurance company for specific coverage decisions. For personalized assistance with insurance appeals in Washington, contact the Washington Insurance Commissioner at 1-800-562-6900.

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