By Counterforce Health Team in Bavencio (avelumab) —

How to Get Bavencio (Avelumab) Covered by Cigna in Washington: Complete Prior Authorization and Appeals Guide

Answer Box: Getting Bavencio Covered by Cigna in Washington

Bavencio requires prior authorization from Cigna. The fastest path: 1) Have your oncologist submit the Cigna prior authorization form with complete platinum chemotherapy history and imaging within 8 weeks, 2) If denied, file internal appeal within 180 days emphasizing medical necessity, 3) Use Washington's external review through the Office of Insurance Commissioner if needed. Success rates are high with proper documentation.

Table of Contents

Coverage Requirements at a Glance

Requirement What It Means Where to Find It Source
Prior Authorization Required before dispensing Cigna Bavencio Policy Cigna
Age Requirement Must be 18+ years old Policy document Cigna
Prescriber Oncologist or consultation required PA form Cigna
Platinum History For urothelial cancer only PA form Cigna
Recent Imaging Within 8 weeks for UC PA form Cigna
Appeals Deadline 180 days from denial WA Insurance Appeals Guide WA OIC

Step-by-Step: Fastest Path to Approval

1. Confirm Your Diagnosis and Treatment History

Who: Patient and oncologist
What: Verify you have metastatic Merkel cell carcinoma OR locally advanced/metastatic urothelial carcinoma
Timeline: Before starting PA process

For urothelial carcinoma, document your platinum-based chemotherapy history (cisplatin or carboplatin). If you haven't progressed on first-line platinum therapy, Bavencio will be for maintenance treatment.

2. Gather Required Documentation

Who: Healthcare team
What: Collect all supporting materials
Timeline: 1-2 days

Essential documents include:

  • Recent imaging studies (within 8 weeks)
  • Complete blood count and metabolic panel
  • Liver function tests
  • Pathology reports confirming diagnosis
  • Prior treatment records and response documentation

3. Submit Prior Authorization Request

Who: Prescribing oncologist
What: Complete Cigna's Bavencio PA form
How: Fax to number on form or submit via Cigna provider portal
Timeline: Standard review takes 7-30 days

Tip: For urgent cases, call Cigna directly and request expedited review with physician attestation.

4. Follow Up on Your Request

Who: Patient or clinic staff
What: Track PA status
Timeline: Check after 7-10 business days

Call Cigna member services or have your clinic check the provider portal for updates.

5. If Denied, File Internal Appeal

Who: Patient or prescriber
What: Submit appeal with additional clinical justification
Timeline: Within 180 days of denial
How: Use Cigna appeal form

Request a peer-to-peer review during this stage—it significantly improves approval odds.

6. Consider External Review (If Needed)

Who: Patient
What: File with Washington's Independent Review Organization
Timeline: Within 180 days of final internal denial
How: Contact WA Office of Insurance Commissioner at 1-800-562-6900

The external reviewer's decision is binding on Cigna.

Coding That Supports Your Request

ICD-10 Diagnosis Codes

Proper coding strengthens your prior authorization request:

Metastatic Merkel Cell Carcinoma: C7B.1
Urothelial Carcinoma: C67.x (specify anatomical location)

Note: Include laterality and specific anatomical sites when applicable. Pathology confirmation should support the diagnosis code.

HCPCS Billing Information

J-Code: J9023 (Injection, avelumab, 10 mg)
NDC: 44087-3535-01 (200 mg/10 mL vial)
Standard Dose: 800 mg IV every 14 days = 80 billable units
Administration: CPT 96413 (first hour) + 96415 (additional hours)

For patients weighing ≤66 kg, weight-based dosing of 10 mg/kg may be more appropriate, resulting in 600 mg (60 units) every 14 days.

Common Denial Reasons & How to Fix Them

Denial Reason How to Overturn Required Documentation
Missing platinum history Submit chemotherapy records Prior treatment summaries, infusion records
No disease progression documentation Provide imaging comparison Radiology reports showing stable disease
Site of care restrictions Request medical necessity override Physician letter explaining why hospital/clinic setting required
Step therapy requirements Document contraindications to preferred agents Medical records showing intolerance or failure
Experimental/investigational Cite FDA approval and guidelines FDA label, NCCN guidelines

Appeals Process in Washington

Washington provides robust consumer protections for insurance denials. Here's your roadmap:

Internal Appeals (Required First Step)

  • Level 1: File within 180 days of denial
  • Level 2: Available if Level 1 denied
  • Timeline: 30 days for standard, 72 hours for expedited
  • Success tip: Request peer-to-peer review and emphasize patient-specific contraindications

External Review (Independent Review Organization)

If internal appeals fail, Washington's external review process offers strong consumer protection:

  • Filing window: 180 days from final internal denial
  • Cost: $60 maximum (refunded if you win)
  • Decision: Binding on Cigna
  • Timeline: 30 days standard, 72 hours expedited

Contact the Washington Office of Insurance Commissioner at 1-800-562-6900 for assistance.

From our advocates: We've seen many Washington patients successfully overturn Cigna denials for specialty cancer drugs by including comprehensive imaging studies and detailed physician letters explaining why standard treatments weren't suitable. The key is thorough documentation that addresses the specific denial reason.

What to Gather Before You Start

Create a complete file with these essentials:

Insurance Information:

  • Cigna member ID card
  • Policy details and formulary information
  • Previous EOBs or denial letters

Medical Records:

  • Pathology reports confirming diagnosis
  • Complete treatment history
  • Recent lab results (CBC, CMP, liver function)
  • Imaging studies within 8 weeks
  • Performance status documentation

Provider Information:

  • Oncologist contact details
  • Clinic DEA and NPI numbers
  • Preferred infusion center details

Scripts for Common Situations

Calling Cigna About PA Status

"Hi, I'm calling to check on prior authorization status for Bavencio, J-code J9023, for member ID [your ID]. The request was submitted on [date]. Can you provide the current status and any additional information needed?"

Requesting Peer-to-Peer Review

"I'm requesting a peer-to-peer review for the denied prior authorization. My oncologist is available [days/times] to discuss the medical necessity with your medical director."

Escalating to Washington OIC

"I need assistance with a Cigna denial for a cancer medication. I've completed internal appeals and would like information about external review options."

Frequently Asked Questions

How long does Cigna prior authorization take in Washington?
Standard reviews take 7-30 days. Expedited reviews (with physician urgency attestation) are processed within 72 hours.

What if Bavencio isn't on Cigna's formulary?
You can request a formulary exception through the same prior authorization process. Emphasize medical necessity and lack of suitable alternatives.

Can I get an expedited appeal in Washington?
Yes, if your physician attests that delays could seriously jeopardize your health. Both internal and external reviews offer expedited pathways.

Does step therapy apply if I tried other treatments outside Washington?
Treatment history from any state counts. Provide complete documentation of prior therapies and their outcomes.

What counts as medical necessity for Bavencio?
FDA-approved indications, appropriate dosing, documented diagnosis, and clinical rationale for why this specific treatment is needed.

How much does external review cost in Washington?
Maximum $60, which is refunded if the external reviewer overturns Cigna's denial.

When should I contact the Washington Insurance Commissioner?
If Cigna doesn't follow proper timelines, denies without clear rationale, or you need help navigating the appeals process.

What if my plan is through my employer?
Most employer plans follow the same Washington appeal rights. Self-funded ERISA plans may have different procedures—contact the Department of Labor if needed.

About Counterforce Health

Counterforce Health specializes in turning insurance denials into successful appeals for complex medications like Bavencio. Their platform analyzes denial letters, identifies the specific denial basis, and creates evidence-backed appeals aligned to each payer's requirements. By pulling the right clinical citations and weaving them with required documentation, they help patients, clinicians, and specialty pharmacies achieve higher approval rates while reducing administrative burden.

For patients facing Cigna denials in Washington, Counterforce Health can provide targeted support that addresses the specific reasons for denial while ensuring all procedural requirements are met for both internal appeals and external review processes.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage decisions depend on individual policy terms and medical circumstances. Always consult with your healthcare provider and insurance company for guidance specific to your situation. For additional support with Washington insurance appeals, contact the Office of Insurance Commissioner at 1-800-562-6900.

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