By Counterforce Health Team in Cometriq (cabozantinib) —

How to Get Cometriq (cabozantinib) Covered by Cigna in Michigan: Complete PA and Appeals Guide

Answer Box: Getting Cometriq (cabozantinib) Covered by Cigna in Michigan

Cometriq requires prior authorization through Cigna and must be dispensed through Accredo specialty pharmacy. Your oncologist submits clinical documentation proving medullary thyroid carcinoma (MTC) diagnosis with standard review completed within 72 hours. If denied, you have 180 days for internal appeals, then 127 days for Michigan DIFS external review—which decides within 60 days (72 hours if expedited). First step today: Have your oncologist call the number on your Cigna ID card to initiate prior authorization while gathering your MTC pathology report and treatment history.

Table of Contents

  1. Read the Denial: Understanding Cigna's Decision
  2. Fixable Causes: Common Issues You Can Resolve
  3. First-Level Appeal: Building Your Case
  4. Peer-to-Peer Review: Direct Doctor Discussion
  5. Michigan External Review: Your Final Option
  6. Coverage Requirements at a Glance
  7. Common Denial Reasons & How to Fix Them
  8. Cost-Saving Options & Patient Support
  9. FAQ: Your Most Common Questions

Read the Denial: Understanding Cigna's Decision

When Cigna denies Cometriq coverage, your denial letter contains crucial information for your appeal. Look for these key elements:

Denial reason codes typically include:

  • Medical necessity not established
  • Non-formulary medication (requires step therapy)
  • Missing clinical documentation
  • Incorrect formulation (Cabometyx tablets vs. Cometriq capsules)

Critical deadlines in your denial letter:

  • 180 days for internal appeals from denial date
  • 127 days for Michigan DIFS external review after final internal denial
  • Expedited timelines available for urgent situations
Note: Cometriq (cabozantinib capsules) and Cabometyx (cabozantinib tablets) are not interchangeable. Cometriq is specifically FDA-approved for metastatic medullary thyroid carcinoma, while Cabometyx covers other cancer types. Using the wrong formulation is a common denial reason.

Fixable Causes: Common Issues You Can Resolve

Before filing an appeal, check if your denial stems from easily correctable issues:

Missing Documentation

  • Pathology report confirming MTC diagnosis with ICD-10 code C73
  • Serum calcitonin levels (elevated >10 pg/mL)
  • Imaging showing metastatic disease
  • Prior therapy documentation if applicable

Pharmacy Benefit vs. Medical Benefit Cometriq must be processed through Cigna's specialty pharmacy benefit, not the medical benefit. Verify your prescription was submitted to Accredo specialty pharmacy.

Coding Issues Ensure your oncologist used the correct:

  • Diagnosis codes (C73 for thyroid cancer, C78.00 for metastatic disease)
  • NDC number for Cometriq capsules (not Cabometyx tablets)
  • Site of care designation

First-Level Appeal: Building Your Case

Step-by-Step: Fastest Path to Approval

  1. Gather Required Documents (Patient/Clinic)
    • Original denial letter
    • Complete medical records showing MTC diagnosis
    • Pathology reports with immunohistochemistry results
    • Submit within 180 days of denial
  2. Prepare Medical Necessity Letter (Oncologist)
    • Document MTC diagnosis with calcitonin levels
    • Explain why Cometriq is medically necessary
    • Reference NCCN guidelines for thyroid cancer
    • Include contraindications to alternative therapies
  3. Submit Appeal (Patient/Clinic)
    • Use Cigna member portal or provider portal
    • Include all supporting documentation
    • Request expedited review if urgent (24-hour timeline)
  4. Track Your Appeal (Patient)
    • Log into myCigna account for status updates
    • Cigna provides decision within 30 days (72 hours if expedited)
    • Prepare for Level 2 appeal if denied

Medical Necessity Letter Checklist for Clinicians

Your letter should address these key points:

  • Problem: "Patient has progressive metastatic medullary thyroid carcinoma confirmed by [pathology findings]"
  • Prior treatments: Document any previous therapies and outcomes
  • Clinical rationale: "Cometriq is FDA-approved specifically for this indication"
  • Guideline support: Reference NCCN thyroid cancer guidelines
  • Monitoring plan: Describe how you'll track treatment response

Peer-to-Peer Review: Direct Doctor Discussion

If your initial appeal is denied, request a peer-to-peer review where your oncologist speaks directly with a Cigna medical director.

How to Request

  • Call Cigna Health Services at 1-800-882-4462
  • Ask for peer-to-peer review for specialty medication denial
  • Provide your case number and member ID

Preparation Talking Points for Your Doctor

  • "Patient has stage IV medullary thyroid carcinoma per biopsy dated [date]"
  • "Cometriq is FDA-approved for this specific indication"
  • "No equally effective lower-cost alternative available"
  • "Delay risks disease progression and patient deterioration"
From our advocates: We've seen peer-to-peer reviews succeed when doctors emphasize the unique nature of MTC compared to other thyroid cancers, and why Cometriq's specific FDA approval matters. Having calcitonin levels and imaging reports readily available during the call strengthens the case significantly.

Michigan External Review: Your Final Option

If Cigna denies your internal appeals, Michigan's Department of Insurance and Financial Services (DIFS) provides independent external review under the Patient's Right to Independent Review Act.

Timeline and Process

Eligibility Requirements

  • Completed Cigna's internal grievance process
  • File within 127 days of final Cigna denial
  • Adverse determination for medical necessity

How to File

  • Online: DIFS External Review Form
  • Phone: 877-999-6442 (8 a.m.–5 p.m. ET, Monday–Friday)
  • Documents needed: Denial letter, service dates, physician notes, explanation of issue

Review Timeline

  • Standard review: Up to 60 days
  • Expedited review: Within 72 hours with physician letter stating delay would harm patient

Binding Decision If the Independent Review Organization approves your case, Cigna must provide coverage. DIFS sends written notice to both you and Cigna.

Coverage Requirements at a Glance

Requirement What It Means Where to Find It Source
Prior Authorization Must get approval before filling Cigna member portal Cigna PA Policy
Specialty Pharmacy Must use Accredo Cigna formulary Express Scripts Formulary
MTC Diagnosis ICD-10 code C73 required Medical records Cigna Coverage Policy
Formulary Tier Tier 4/5 specialty Plan documents Cigna Formulary
Appeal Deadline 180 days from denial Denial letter Michigan DIFS

Common Denial Reasons & How to Fix Them

Denial Reason How to Overturn Required Documents
"Not medically necessary" Submit pathology report showing MTC Biopsy results, calcitonin levels, imaging
"Use Cabometyx instead" Emphasize Cometriq's specific MTC approval FDA labeling comparison
"Try step therapy first" Document contraindications to alternatives Medical records, allergy history
"Wrong pharmacy benefit" Resubmit through Accredo specialty pharmacy New prescription to Accredo

Cost-Saving Options & Patient Support

Manufacturer Support

  • Exelixis Patient Access Program may provide copay assistance
  • Contact manufacturer directly for eligibility requirements
  • Income-based financial assistance available

State Programs Michigan residents may qualify for additional support through Medicaid expansion ("Healthy Michigan") if income-eligible.

Foundation Grants Several cancer-focused foundations provide medication assistance for thyroid cancer patients. Research options through your cancer center's financial counselor.

FAQ: Your Most Common Questions

How long does Cigna prior authorization take for Cometriq in Michigan? Standard review takes 72 hours; expedited review takes 24 hours if your doctor certifies urgency.

What if Cometriq is non-formulary on my Cigna plan? You can request a formulary exception with clinical justification. Your doctor must demonstrate medical necessity and lack of suitable alternatives.

Can I request an expedited appeal in Michigan? Yes, both Cigna internal appeals and Michigan DIFS external reviews offer expedited timelines when delays would jeopardize your health.

Does step therapy apply if I've tried other treatments outside Michigan? Yes, document any prior therapies regardless of where you received them. This history supports your case for Cometriq.

What happens if Michigan DIFS approves my external review? Cigna must provide coverage within 3 business days of the binding decision.

How much does Cometriq cost with Cigna coverage? As a Tier 4/5 specialty drug, expect 25-40% coinsurance after meeting your deductible, potentially $3,000-7,000 annually depending on your specific plan.

Getting insurance approval for specialty cancer medications like Cometriq can feel overwhelming, but Michigan patients have strong appeal rights and multiple pathways to coverage. Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals by analyzing denial letters, plan policies, and clinical notes to draft point-by-point rebuttals aligned to each payer's specific rules. Their platform pulls the right citations—FDA labeling, peer-reviewed studies, and specialty guidelines—and weaves them into appeals with required clinical facts like diagnosis codes, prior treatment failures, and dosing rationale.

The key is acting quickly within Michigan's deadlines while building a comprehensive case that demonstrates medical necessity. Whether you're navigating Cigna's prior authorization process or preparing for Michigan DIFS external review, having the right documentation and understanding each step improves your chances of approval.

Sources & Further Reading

Disclaimer: 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. Coverage policies and procedures may change; verify current requirements with official sources.

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