By Counterforce Health Team in Cometriq (cabozantinib) —

How to Get Cometriq (Cabozantinib) Covered by Cigna in Ohio: Coding, Prior Authorization, and Appeals Guide

Answer Box: Getting Cometriq Covered by Cigna in Ohio

Cometriq (cabozantinib capsules) requires prior authorization from Cigna for metastatic medullary thyroid carcinoma. Key steps: 1) Submit PA with ICD-10 code C73, progression documentation, and Cometriq-specific prescription (not Cabometyx tablets), 2) If denied, file internal appeal within 180 days, 3) Request external review through Ohio Department of Insurance if needed. Start today: Call Cigna at the number on your insurance card to confirm PA requirements and get the correct form.

Table of Contents

Coding Basics: Medical vs. Pharmacy Benefit

Cometriq (cabozantinib capsules) typically falls under medical benefit rather than pharmacy benefit, which affects how it's coded and billed. As an oral chemotherapeutic for metastatic medullary thyroid carcinoma (MTC), Cigna usually processes Cometriq through their specialty pharmacy partner Express Scripts or Accredo.

Coverage Path Overview:

  • Medical Benefit: Billed using HCPCS J-codes through oncology practices
  • Specialty Pharmacy: Managed through Express Scripts/Accredo with prior authorization
  • Prior Authorization Required: For all Cometriq prescriptions regardless of benefit type
Note: Cigna's specialty drug management varies by plan type. Commercial plans typically use Express Scripts, while Medicare plans may have different pathways.

ICD-10 Mapping for Medullary Thyroid Carcinoma

Proper diagnosis coding is critical for Cometriq approval. The primary code is C73 for malignant neoplasm of thyroid gland, with additional codes for metastatic sites.

Primary and Secondary Codes

Code Description Documentation Required
C73 Malignant neoplasm of thyroid gland (includes MTC) Pathology report with calcitonin staining
C78.0 Secondary malignant neoplasm of lung Chest imaging showing metastases
C78.7 Secondary malignant neoplasm of liver CT/MRI with liver lesions
C78.6 Secondary malignant neoplasm of retroperitoneum Abdominal imaging

Supporting Documentation Words

Your physician notes should include specific language that supports the diagnosis:

  • "Progressive metastatic medullary thyroid carcinoma"
  • "Elevated serum calcitonin levels"
  • "Radiographic progression on recent imaging"
  • "Pathology consistent with medullary thyroid carcinoma"

According to claims data analysis, MTC identification requires ≥2 C73 claims plus thyroid surgery within 2 years, plus ≥2 post-operative serum calcitonin measurements to distinguish from follicular cancers.

Product Coding: HCPCS, NDC, and Billing Units

Cometriq lacks a specific HCPCS J-code, so billing uses the generic oral chemotherapy code with specific NDC numbers.

HCPCS and NDC Information

HCPCS Code: J8999 (prescription drug, oral, chemotherapeutic, NOS)

  • Specify "Cometriq (cabozantinib)" in claim notes
  • Bill by total milligrams administered

NDC Numbers:

  • 42388-011-14 (20 mg capsules)
  • 42388-012-14 (40 mg capsules)
  • 42388-013-14 (60 mg capsules)
  • 42386-120-06 (80 mg capsules)

Dosing and Units Conversion

Standard MTC dosing is 140 mg daily, typically supplied as:

  • 7 capsules per day (various combinations of 20 mg capsules)
  • 30-capsule supply = approximately half-month at full dose
  • Monthly supply = 112 capsules for 140 mg daily dosing
Critical: Never substitute Cometriq capsules with Cabometyx tablets. These are different formulations with distinct FDA approvals and bioavailability profiles.

Clean Prior Authorization Request

A successful Cometriq PA submission includes specific clinical and administrative elements that align with Cigna's medical necessity criteria.

Required Components Checklist

✅ Diagnosis Documentation

  • Pathology report confirming medullary thyroid carcinoma
  • Recent imaging showing progression or metastatic disease
  • Elevated calcitonin and/or CEA levels

✅ Treatment History

  • Documentation of prior therapies tried and failed
  • Contraindications to alternative treatments
  • Performance status and organ function labs

✅ Prescription Specifics

  • Cometriq capsules only (specify strength and daily dose)
  • Prescriber attestation of medical necessity
  • Expected duration of treatment

Sample PA Documentation

Clinical Summary Example: "Patient with pathologically confirmed metastatic medullary thyroid carcinoma (ICD-10 C73) with progressive disease on recent CT imaging. Calcitonin level elevated at [value]. Previous treatments include [list prior therapies]. Requesting Cometriq 140 mg daily (capsules) per FDA-approved indication for progressive metastatic MTC."

Frequent Coding and Billing Pitfalls

Common errors can lead to automatic denials or processing delays. Here are the most frequent issues we see with Cometriq claims:

Top 5 Billing Mistakes

  1. Wrong Formulation: Submitting Cabometyx tablets instead of Cometriq capsules
    • Fix: Always specify "Cometriq capsules" and use correct NDC numbers
  2. Missing Progression Documentation: Submitting for stable disease
    • Fix: Include recent imaging reports showing progression or metastatic spread
  3. Incorrect Units: Billing by tablets instead of capsules or wrong mg calculations
    • Fix: Use capsule count and verify total daily mg dose
  4. Off-Label Use: Requesting for non-MTC cancers
    • Fix: Cometriq is FDA-approved only for metastatic MTC; use Cabometyx for other indications
  5. Incomplete Prior Authorization: Missing required clinical documentation
    • Fix: Submit complete PA package with all supporting documents upfront

Documentation Red Flags

Avoid these phrases that commonly trigger denials:

  • "Stable disease" (implies non-progressive)
  • "Prophylactic use" (not an approved indication)
  • "Patient preference" (insufficient medical necessity)

Verification with Cigna Resources

Before submitting your PA or appeal, verify current requirements through official Cigna channels.

Key Verification Steps

  1. Check Formulary Status
    • Log into Cigna member portal or call customer service
    • Verify Cometriq's tier placement and coverage restrictions
    • Confirm whether step therapy applies
  2. Confirm PA Requirements
    • Contact Express Scripts at 1-800-835-3784 for specialty drug PA forms
    • For Accredo patients, call 1-800-803-2523
    • Download current PA forms from Cigna provider portal
  3. Review Plan-Specific Policies
    • Commercial vs. Medicare coverage may differ
    • Ohio Medicaid managed care plans have separate processes
    • Self-funded employer plans follow ERISA rules
Tip: Always verify information is current, as formulary and PA requirements change annually.

Appeals Process for Ohio Residents

If Cigna denies your Cometriq request, Ohio residents have specific rights and timelines for appeals.

Internal Appeals (Required First Step)

Level 1 Internal Appeal:

  • Timeline: Must file within 180 days of denial
  • Review Period: 30 days for standard, 72 hours for expedited
  • Required Documents: Denial letter, medical records, physician necessity letter

Level 2 Internal Appeal:

  • Timeline: 30 days after Level 1 denial
  • Review Period: 30 days for standard review
  • Additional Evidence: Can submit new clinical information

External Review (Ohio-Specific Process)

After exhausting internal appeals, Ohio residents can request external review through the Ohio Department of Insurance.

External Review Process:

  • Eligibility: Available after completing internal appeals
  • Timeline: 180 days from final internal denial to request
  • Contact: Ohio Department of Insurance at 1-800-686-1526
  • Decision: Binding on insurer if approved; typically within 30 days

Required for External Review:

  • Completed internal appeal process
  • Medical necessity determination (not purely contractual exclusion)
  • Submit request through your health plan, which notifies ODI
Important: Self-funded employer plans are governed by federal ERISA law, not Ohio's external review process. However, many voluntarily use similar procedures.

Cost Assistance and Financial Support

Cometriq's cash price of approximately $18,938 per month makes financial assistance crucial for most patients.

Manufacturer Support Programs

Exelixis Access Services (EASE):

  • Copay assistance: Up to $25/month for eligible commercially insured patients
  • Free drug program: For patients with income ≤400% of Federal Poverty Level
  • Covers both Cometriq and Cabometyx
  • Apply at: Exelixis website

Additional Resources

  • Medicare patients: 2025 out-of-pocket cap at $2,000 provides significant savings
  • Medicare Prescription Payment Plan: Spreads costs over 12 months
  • State programs: Ohio may have additional assistance through OSHIIP (1-800-686-1578)

Quick Audit Checklist

Use this checklist before submitting any Cometriq PA or appeal:

Pre-Submission Review

  • ICD-10 code C73 with appropriate metastatic site codes
  • HCPCS J8999 with "Cometriq (cabozantinib)" specified
  • Correct NDC numbers for capsule formulation
  • Pathology report confirming MTC diagnosis
  • Recent imaging showing progression or metastases
  • Elevated calcitonin/CEA levels documented
  • Prior treatment history and failures documented
  • Prescriber attestation of medical necessity
  • Correct daily dose and duration specified
  • All required forms completed and signed
  • Supporting clinical notes attached

Common Missing Elements

  • Recent lab values (calcitonin, CEA, liver function)
  • Performance status documentation
  • Contraindications to alternative treatments
  • Weight-based dosing rationale if applicable

FAQ: Common Questions

Q: How long does Cigna prior authorization take for Cometriq in Ohio? A: Standard reviews take 72 hours to 15 business days. Expedited reviews (for urgent medical needs) are completed within 24-72 hours. Timeline varies by plan type and completeness of submission.

Q: What if Cometriq is not on Cigna's formulary? A: You can request a formulary exception through Cigna's standard process. Your physician must demonstrate medical necessity and provide clinical rationale for why formulary alternatives are inappropriate.

Q: Can I request an expedited appeal if my treatment is delayed? A: Yes, if the delay would seriously jeopardize your health or ability to regain maximum function. Expedited appeals in Ohio must be decided within 72 hours for standard plans.

Q: Does step therapy apply if I failed treatments in another state? A: Step therapy requirements typically transfer between states if properly documented. Provide records showing prior treatment failures or contraindications to support a step therapy override.

Q: What's the difference between Cometriq and Cabometyx for insurance purposes? A: Cometriq (capsules) is only FDA-approved for metastatic medullary thyroid carcinoma. Cabometyx (tablets) is approved for other cancers but not MTC. They cannot be substituted for insurance coverage.

Q: How do I find Ohio-specific help with my appeal? A: Contact the Ohio Department of Insurance Consumer Services Division at 1-800-686-1526. They can assist with questions about appeals and external review processes.

From Our Advocates

"We've seen Cigna denials overturned when physicians clearly document progression with specific imaging dates and calcitonin trends. The key is painting a complete clinical picture that shows why Cometriq is medically necessary right now, not just appropriate. Include every piece of supporting evidence upfront rather than submitting minimal documentation and hoping for approval."

About Counterforce Health

Counterforce Health specializes in turning insurance denials into successful appeals through evidence-based advocacy. Our platform helps patients, clinicians, and specialty pharmacies navigate complex prior authorization requirements by identifying denial reasons and crafting targeted rebuttals aligned with each payer's specific policies. We focus on specialty medications like Cometriq, ensuring that clinical evidence meets payer criteria while tracking deadlines and procedural requirements.

For Cigna members in Ohio facing Cometriq denials, Counterforce Health provides the documentation and appeals expertise needed to demonstrate medical necessity according to both FDA labeling and Cigna's internal guidelines.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage policies vary by plan and change frequently. Always verify current requirements with Cigna and consult your healthcare provider for medical decisions. For official guidance on Ohio insurance appeals, contact the Ohio Department of Insurance at 1-800-686-1526.

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