By Counterforce Health Team in Amvuttra (vutrisiran) —

Getting Amvuttra (Vutrisiran) Covered by Cigna in Texas: Complete Coding, Billing & Appeals Guide

Answer Box: Getting Amvuttra Covered by Cigna in Texas

Eligibility: Adults with confirmed TTR amyloidosis (hATTR polyneuropathy or ATTR cardiomyopathy) with genetic testing documentation. Fastest path: Submit prior authorization with ICD-10 code E85.2, HCPCS J0225 (25 units), NDC 71336-1003-01, and specialist evaluation. First step today: Gather genetic testing results and cardiac imaging (for cardiomyopathy) or neurological evaluation (for polyneuropathy), then contact your prescribing physician to initiate Cigna's prior authorization form. Texas residents have 180 days to appeal denials and access independent external review through the Texas Department of Insurance.

Table of Contents

  1. Coding Basics: Medical vs. Pharmacy Benefit Paths
  2. ICD-10 Mapping and Documentation Requirements
  3. Product Coding: HCPCS, J-Code, and NDC Overview
  4. Clean Prior Authorization Request Anatomy
  5. Frequent Coding and Billing Pitfalls
  6. Verification Steps with Cigna Resources
  7. Appeals Playbook for Texas Residents
  8. Quick Audit Checklist

Coding Basics: Medical vs. Pharmacy Benefit Paths

Amvuttra (vutrisiran) typically falls under the medical benefit when administered by a healthcare provider in a clinical setting. This quarterly subcutaneous injection requires specific coding to ensure proper reimbursement and avoid denials.

Medical Benefit Path (Most Common):

  • Billed by the administering physician or facility
  • Uses HCPCS J-codes and administration CPT codes
  • Requires prior authorization through Cigna's medical management
  • Standard 5 business day response time for authorization requests

Pharmacy Benefit Path (Less Common):

  • May apply for specialty pharmacy dispensing
  • Requires verification with Express Scripts (Cigna's pharmacy benefit manager)
  • Still uses same HCPCS codes but different submission process
Note: Always verify benefit coverage with Cigna before assuming the pathway, as some plans may have specific routing requirements for specialty injectables.

ICD-10 Mapping and Documentation Requirements

Proper diagnosis coding is critical for Amvuttra approval. Cigna requires specific ICD-10 codes that match the FDA-approved indications.

Primary ICD-10 Codes

Condition ICD-10 Code Documentation Required
Hereditary ATTR Polyneuropathy E85.2 Genetic testing confirming TTR pathogenic variant
ATTR Cardiomyopathy I43 Cardiac imaging showing amyloid deposits
Wild-type ATTR E85.82 Diagnostic confirmation via biopsy or imaging

Supporting Documentation Words

When documenting medical necessity, include these key phrases that support proper coding:

  • "Confirmed TTR pathogenic variant"
  • "Symptomatic polyneuropathy with functional impairment"
  • "Cardiac amyloidosis with heart failure symptoms"
  • "Progressive neuropathy despite standard care"
  • "Echocardiogram demonstrates cardiac involvement"

Counterforce Health specializes in transforming clinical documentation into targeted appeals that align with payer requirements, helping clinicians navigate complex prior authorization processes for specialty medications like Amvuttra.

Product Coding: HCPCS, J-Code, and NDC Overview

Essential Coding Information

HCPCS Code: J0225 ("Injection, vutrisiran, 1 mg")

  • Effective January 1, 2023
  • Each billable unit = 1 mg
  • Standard dose = 25 mg = 25 units

NDC Number: 71336-1003-01 (25 mg/0.5 mL prefilled syringe)

  • Report as "UN1" for unit type
  • Enter 25 total units for full dose

Administration Code: CPT 96372 (subcutaneous injection)

Units Calculation

Amvuttra is dosed as 25 mg every 3 months. Here's the billing math:

  • 1 prefilled syringe = 25 mg
  • HCPCS J0225 = 1 mg per unit
  • Bill 25 units of J0225 per quarterly injection

When Modifiers Apply

  • UD modifier: Required for 340B providers
  • JW modifier: Use if drug wastage occurs (document amount)
  • GA modifier: May be required for advance beneficiary notices

Clean Prior Authorization Request Anatomy

A successful Amvuttra prior authorization should include these components in order:

Required Clinical Documentation

  1. Genetic Testing Results
    • Laboratory report confirming TTR pathogenic variant
    • Include specific mutation identified
  2. Specialist Evaluation
    • Neurologist assessment for polyneuropathy cases
    • Cardiologist evaluation for cardiomyopathy cases
  3. Diagnostic Imaging (for cardiomyopathy)
    • Echocardiogram showing cardiac involvement
    • Cardiac MRI if available
  4. Baseline Laboratory Values
    • Vitamin A levels (monitoring requirement)
    • Liver function tests
    • Kidney function assessment
  5. Treatment History
    • Prior therapies attempted and outcomes
    • Contraindications to alternative treatments

Example Claim Line Format

Line 24D: J0225
Line 24G: 25 (units)
Line 21: E85.2 (diagnosis)
NDC: 71336-1003-01
Administration: 96372

Frequent Coding and Billing Pitfalls

Common Unit Conversion Errors

Wrong: Billing 1 unit for entire 25 mg dose Correct: Billing 25 units (1 unit = 1 mg)

Wrong: Using outdated J3490 (unclassified) code Correct: Using J0225 (specific vutrisiran code)

Missing Documentation Pitfalls

  • Submitting prior authorization without genetic testing confirmation
  • Failing to include specialist evaluation from neurologist or cardiologist
  • Missing cardiac imaging for cardiomyopathy cases
  • Inadequate documentation of prior therapy failures

Timing and Frequency Errors

  • Billing more frequently than every 3 months
  • Not documenting the quarterly dosing schedule
  • Submitting claims without proper date spacing

Verification Steps with Cigna Resources

Before submitting your prior authorization or claim, verify these details:

Pre-Submission Checklist

  1. Confirm Patient Eligibility
    • Active Cigna coverage
    • Specialty drug benefits included
    • Prior authorization requirements current
  2. Verify Coding Accuracy
    • J0225 is covered under current policy
    • NDC matches Cigna formulary
    • Units calculated correctly (25 per dose)
  3. Check Cigna-Specific Requirements
    • Review current Cigna policy
    • Confirm site of care restrictions
    • Verify prescriber specialty requirements

Cigna Contact Resources

  • Provider Services: 1-800-88-CIGNA
  • Prior Authorization Fax: (verify current number with provider services)
  • Online Portal: Cigna for Healthcare Professionals

Appeals Playbook for Texas Residents

If your initial prior authorization is denied, Texas law provides strong appeal rights with specific timelines.

Internal Appeal Process

Timeline: 180 days from denial letter date to file Response Time: 30 days for Cigna's decision Required Form: Request for Health Care Provider Payment Review

What to Include:

  • Original denial letter and EOB
  • Additional medical documentation supporting medical necessity
  • Specialist letter of support
  • Published clinical evidence supporting treatment

External Review (IRO) Process

If internal appeal fails, Texas automatically provides access to Independent Review Organization (IRO) review.

Process: Automatic escalation to Level 2 external review Timeline: 20 days for standard review, 5 days for urgent cases Cost: Paid by Cigna, not the patient Decision: Binding on the insurance company

Expedited Appeals

For urgent cases where delay could jeopardize health:

  • Request expedited internal and external review simultaneously
  • Must demonstrate immediate health risk
  • Faster timelines: 72 hours for internal, 5 days for external

Texas-Specific Resources

  • Texas Department of Insurance: 1-800-252-3439
  • Office of Public Insurance Counsel: 1-877-611-6742
  • IRO Information Line: 1-866-554-4926

When appealing in Texas, Counterforce Health can help transform denial letters into targeted, evidence-backed appeals that address specific payer concerns and increase approval chances.

Quick Audit Checklist

Before submitting any Amvuttra request to Cigna, verify:

Documentation Checklist

  • TTR genetic testing results attached
  • Specialist evaluation (neurologist or cardiologist) included
  • Cardiac imaging for cardiomyopathy cases
  • Baseline vitamin A and liver function labs
  • Prior therapy documentation with outcomes

Coding Checklist

  • HCPCS J0225 used (not J3490)
  • 25 units billed for 25 mg dose
  • Correct NDC: 71336-1003-01
  • Appropriate ICD-10: E85.2 or I43
  • Administration code 96372 included

Submission Checklist

  • Prior authorization form completed
  • All required attachments included
  • Prescriber signature and date current
  • Patient demographic information accurate
  • Site of care specified and appropriate

Coverage at a Glance

Requirement What It Means Where to Find It
Prior Authorization Required before coverage Cigna PA Form
Genetic Testing TTR variant confirmation needed Laboratory genetics report
Specialist Evaluation Neurologist or cardiologist assessment Medical records/consultation notes
Quarterly Dosing 25 mg every 3 months maximum FDA prescribing information
Site of Care Least intensive appropriate setting Cigna medical policy

FAQ

How long does Cigna prior authorization take for Amvuttra in Texas? Standard response time is 5 business days. Expedited requests for urgent cases can be processed within 72 hours.

What if Amvuttra is non-formulary on my Cigna plan? Submit a formulary exception request with clinical justification. Include evidence that formulary alternatives are inappropriate or have failed.

Can I request an expedited appeal in Texas? Yes, if delay would jeopardize your health. Texas allows concurrent expedited internal and external review for urgent cases.

Does step therapy apply to Amvuttra? Cigna may require trial of other TTR-targeting therapies first, depending on your specific indication and plan design.

What happens if my appeal is denied? Texas provides automatic access to independent external review. The IRO decision is binding on Cigna if they overturn the denial.

Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into successful appeals by creating targeted, evidence-backed requests that align with payer-specific requirements. Our platform analyzes denial letters and drafts point-by-point rebuttals using the right clinical evidence and operational details that payers expect.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage policies and appeal processes may vary by plan and change over time. Always consult current payer policies and speak with your healthcare provider about treatment decisions. For the most current Texas insurance appeal information, contact the Texas Department of Insurance at 1-800-252-3439.

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