How to Get Cerezyme (Imiglucerase) Covered by Cigna in Michigan: Complete Prior Authorization and Appeals Guide
Answer Box: Getting Cerezyme Covered by Cigna in Michigan
Eligibility: Cigna covers Cerezyme (imiglucerase) for confirmed Type 1 Gaucher disease with prior authorization through the medical benefit. No step therapy is required.
Fastest path: Have your specialist submit a PA request via CoverMyMeds or Cigna's provider portal with enzyme testing (β-glucocerebrosidase <15% normal), genetic confirmation, and clinical documentation. Standard review takes 5 business days; expedited review 24 hours.
First step today: Confirm your diagnosis documentation is complete and contact your hematologist or geneticist to initiate the PA process. Cerezyme must be filled through Accredo Specialty Pharmacy once approved.
Table of Contents
- Who Should Use This Guide
- Member & Plan Basics
- Clinical Criteria Requirements
- Coding and Billing Information
- Documentation Packet Essentials
- Submission Process
- Specialty Pharmacy Requirements
- After Submission: Tracking Your Request
- Appeals Process in Michigan
- Common Denial Reasons & Solutions
- FAQ
Who Should Use This Guide
This guide is designed for Michigan patients with Type 1 Gaucher disease and their healthcare providers who need Cerezyme (imiglucerase) covered by Cigna insurance. You'll benefit from this resource if you're:
- Starting Cerezyme therapy for the first time
- Transferring from another insurer or specialty pharmacy
- Facing a prior authorization denial
- Switching from another enzyme replacement therapy
Expected outcome: With complete documentation, most medically appropriate Cerezyme requests receive approval within 5 business days. If initially denied, Michigan's robust appeals process provides additional pathways to coverage.
Member & Plan Basics
Coverage Requirements
| Requirement | Details | Verification |
|---|---|---|
| Active Coverage | Current Cigna medical benefits | Check member ID card or call member services |
| Plan Type | Most commercial and Medicare Advantage plans cover Cerezyme | Review Summary of Benefits |
| Prior Authorization | Required for all Cerezyme requests | Submit through medical benefit, not pharmacy |
| Deductible | May apply based on plan design | Contact Cigna at number on your card |
Note: Cerezyme is always covered under the medical benefit due to IV infusion requirements, not the pharmacy benefit.
Clinical Criteria Requirements
Diagnosis Confirmation
Cigna requires documented Type 1 Gaucher disease with:
- Enzyme deficiency: β-glucocerebrosidase activity <15% of normal range
- Genetic testing: GBA1 gene mutation confirmation
- Clinical manifestations: Evidence of organomegaly, cytopenia, or bone involvement
- ICD-10 code: E75.22 (Gaucher disease)
No Step Therapy Requirements
Unlike some specialty medications, Cigna does not require step therapy for Cerezyme as first-line treatment for Type 1 Gaucher disease. This means you don't need to try and fail other therapies first.
Prescriber Requirements
- Must be prescribed by a specialist experienced in Gaucher disease
- Typically hematologist, geneticist, or metabolic disease specialist
- Provider must document expertise in enzyme replacement therapy
Coding and Billing Information
Essential Billing Codes
| Code Type | Value | Description |
|---|---|---|
| HCPCS J-Code | J1786 | Injection, imiglucerase, 10 units |
| NDC | 58468-0312-01 | 400-unit vial (verify with supplier) |
| ICD-10 | E75.22 | Type 1 Gaucher disease |
| CPT | 96365, 96366 | IV infusion administration |
Unit Calculations
- Billing units: 1 unit of J1786 = 10 units of imiglucerase
- Example: 70 kg patient at 15 units/kg every 2 weeks = 1,050 units total = 105 billing units of J1786
- Vial requirements: 3 vials needed (rounded up from 2.6 vials)
- JW modifier: Use for discarded drug when partial vials are wasted
Documentation Packet Essentials
Provider Note Requirements
Your specialist's documentation must include:
- Confirmed diagnosis with enzyme and genetic test results
- Current clinical status including organ sizes, blood counts, bone involvement
- Treatment goals and expected outcomes
- Dosing rationale based on patient weight and disease severity
- Administration plan including infusion site and frequency
Letter of Medical Necessity Components
A strong medical necessity letter should address:
- Clinical presentation and symptom severity
- Diagnostic test results with specific enzyme activity levels
- Treatment rationale citing FDA labeling and clinical guidelines
- Monitoring plan for treatment response and safety
- Alternative therapy considerations and why Cerezyme is most appropriate
Required Attachments
- Recent laboratory results (CBC, comprehensive metabolic panel)
- Imaging studies (MRI for bone involvement, ultrasound for organomegaly)
- Genetic testing report confirming GBA1 mutations
- Previous treatment records if switching therapies
Submission Process
Electronic Submission (Preferred)
- CoverMyMeds platform: Most efficient option with real-time status updates
- Cigna provider portal: Direct submission through Cigna's system
- EHR integration: SureScripts electronic prior authorization
Traditional Submission
- Fax: (855) 840-1678 for standard requests
- Urgent requests: Call (800) 882-4462 for expedited review
Required Form Fields
Ensure all sections are complete to avoid processing delays:
- Patient demographics and insurance information
- Provider NPI and specialty designation
- Detailed diagnosis with ICD-10 code
- Requested dosing and frequency
- Clinical justification narrative
Specialty Pharmacy Requirements
Accredo Enrollment Process
Once your PA is approved, Cerezyme must be filled through Accredo Specialty Pharmacy, Cigna's preferred provider:
- Prescription routing: Provider sends prescription directly to Accredo
- Patient enrollment: Accredo contacts patient to set up services
- Insurance verification: Accredo coordinates benefits and copay assistance
- Delivery scheduling: Home delivery or infusion center coordination
Contact Information
- Accredo phone: (866) 759-1557
- Prescription fax: (888) 302-1028
- Patient portal: Available after enrollment
Transferring from Another Pharmacy
- Requires new prescription (transfers aren't automatic)
- Full clinical documentation must be resubmitted
- Allow extra time to avoid treatment gaps
After Submission: Tracking Your Request
Timeline Expectations
| Review Type | Processing Time | When to Use |
|---|---|---|
| Standard | 5 business days | Most requests |
| Expedited | 24 hours | Urgent medical situations |
| Peer-to-peer | Additional 1-2 days | Complex cases requiring discussion |
Status Monitoring
- Online portals: Check CoverMyMeds or Cigna provider portal
- Phone follow-up: Call Cigna prior authorization team
- Documentation: Record confirmation numbers and representative names
What to Record
Keep detailed notes including:
- Submission date and method
- Confirmation or reference numbers
- Representative names and direct phone numbers
- Any additional information requested
Appeals Process in Michigan
If your initial request is denied, Michigan provides strong patient protections through a structured appeals process.
Internal Appeals (First Step)
- Timeline: Submit within 180 days of denial
- Process: Request reconsideration with additional clinical evidence
- Documentation: Include new studies, peer-reviewed literature, or specialist opinions
External Review (Independent)
Michigan's external review process is managed by the Department of Insurance and Financial Services (DIFS):
- Timeline: 127 days after final internal denial to request external review
- Process: Independent Review Organization evaluates medical necessity
- Decision: Binding determination within 60 days (72 hours for expedited)
- Contact: DIFS at (877) 999-6442
Expedited Appeals
For urgent situations where delay could harm your health:
- Requires physician letter documenting urgency
- 72-hour decision timeline
- Available for both internal and external reviews
Common Denial Reasons & Solutions
| Denial Reason | Solution Strategy |
|---|---|
| Incomplete documentation | Submit comprehensive enzyme testing, genetic results, and clinical notes |
| Non-specialist prescriber | Transfer care to hematologist or geneticist |
| Dosing outside parameters | Provide clinical justification based on patient-specific factors |
| Alternative therapy not tried | Emphasize no step therapy requirement for Cerezyme |
| Medical necessity questioned | Include FDA labeling, treatment guidelines, and outcomes data |
From our advocates: We've seen cases where initial denials were overturned simply by resubmitting with complete genetic testing results and a detailed letter from a Gaucher disease specialist. The key is thorough documentation from the start—it saves time and reduces stress for families dealing with this rare condition.
Counterforce Health: Streamlining Your Appeals Process
Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into targeted, evidence-backed appeals. The platform analyzes denial letters, plan policies, and clinical notes to identify the specific denial basis and draft point-by-point rebuttals aligned to each plan's requirements.
For Cerezyme appeals, Counterforce Health pulls the right citations—FDA labeling, peer-reviewed studies, and specialty guidelines—while ensuring all required clinical facts are properly documented. The system produces letters that meet procedural requirements and tracks deadlines, helping families navigate complex appeals while clinicians save time with streamlined templates.
FAQ
Q: How long does Cigna prior authorization take for Cerezyme in Michigan? A: Standard review takes up to 5 business days. Expedited review for urgent cases is completed within 24 hours.
Q: What if Cerezyme is non-formulary on my plan? A: You can request a formulary exception with clinical documentation showing medical necessity. The appeals process applies if initially denied.
Q: Can I request an expedited appeal in Michigan? A: Yes, both internal and external expedited appeals are available when delay could harm your health. Requires physician documentation of urgency.
Q: Does step therapy apply if I've used other ERTs outside Michigan? A: Document previous therapies and outcomes. Cigna doesn't require step therapy for Cerezyme, but prior treatment history strengthens your case.
Q: What's the difference between medical and pharmacy benefits for Cerezyme? A: Cerezyme is always covered under medical benefits due to IV infusion requirements. Never submit through pharmacy benefits.
Q: How do I find a Gaucher disease specialist in Michigan? A: Contact the National Gaucher Foundation or major medical centers like University of Michigan or Henry Ford Health System.
Q: What if I can't afford the copay? A: Sanofi offers patient assistance programs. Contact their CareConnectPSS program at (800) 745-4447 for eligibility information.
Q: Can I appeal to the state if Cigna denies coverage? A: Yes, Michigan's DIFS provides independent external review after internal appeals are exhausted. The decision is binding on your insurer.
Sources & Further Reading
- Cigna Cerezyme Coverage Policy
- Michigan DIFS External Review Information
- Cerezyme Prescribing Information (FDA)
- CoverMyMeds Prior Authorization Platform
- Accredo Specialty Pharmacy Services
- Sanofi Cerezyme Support Resources
Disclaimer: This information is for educational purposes and does not constitute medical advice. Always consult with your healthcare provider and insurance company for specific coverage decisions. Coverage policies and requirements may change. For the most current information, contact Cigna directly or visit their official website. If you need assistance with complex appeals, consider working with Counterforce Health to strengthen your case with evidence-backed documentation.
Powered by Counterforce Health—AI that turns drug denials into evidence-based appeals patients and clinicians can submit today.