By Counterforce Health Team in Crysvita (burosumab) —

How to Get Crysvita (burosumab) Covered by Cigna in Georgia: Complete Prior Authorization and Appeals Guide

Quick Answer: Getting Crysvita (burosumab) Covered by Cigna in Georgia

Eligibility: Crysvita requires prior authorization from Cigna for X-linked hypophosphatemia (XLH) or tumor-induced osteomalacia (TIO). Fastest path: Submit complete documentation including genetic testing (PHEX mutation), low serum phosphorus labs, and specialist attestation through Cigna's provider portal or Accredo specialty pharmacy. First step today: Verify your plan uses Accredo for specialty drugs and download the current Cigna prior authorization form. Georgia advantage: If denied, you have strong external review rights through the Georgia Department of Insurance within 60 days.

Table of Contents

  1. What This Guide Covers
  2. Before You Start: Plan Verification
  3. Gather Required Documentation
  4. Submit Your Prior Authorization Request
  5. Follow-Up and Tracking
  6. Understanding Timelines in Georgia
  7. If You Need More Information
  8. If Your Request is Denied
  9. Renewal and Re-Authorization
  10. Quick Reference Checklist
  11. Frequently Asked Questions

What This Guide Covers

This comprehensive guide helps patients and clinicians navigate Cigna's prior authorization process for Crysvita (burosumab) in Georgia. Whether you're dealing with X-linked hypophosphatemia (XLH) or tumor-induced osteomalacia (TIO), we'll walk you through every step from initial submission to appeals.

Who this helps: Patients with confirmed XLH or TIO diagnoses, their caregivers, and healthcare providers submitting prior authorization requests to Cigna in Georgia.

Expected outcomes: With complete documentation, most requests are approved within 72 hours. If denied, Georgia's external review process provides strong patient protections with binding decisions that insurers must honor.

Before You Start: Plan Verification

Confirm Your Coverage Details

Check these essentials first:

  • Log into myCigna to verify your current benefits
  • Confirm Crysvita is covered under your pharmacy benefit (not medical)
  • Identify your formulary tier—Crysvita is typically Tier 5 (Specialty)
  • Verify Accredo is your required specialty pharmacy

Plan type matters: Fully insured Georgia plans follow state regulations for appeals. Self-funded ERISA plans may have different rules—check your Summary Plan Description.

Formulary Status Check

Coverage Aspect Typical Status What It Means
Prior Authorization Required Must get approval before filling
Formulary Tier Tier 5 (Specialty) Highest copay tier
Quantity Limits Weight-based Dosing tied to patient weight
Step Therapy May apply Might need to try alternatives first
Specialty Pharmacy Accredo required Cannot fill at retail pharmacy

Source: Cigna Specialty Drug List

Gather Required Documentation

Core Requirements for XLH

Essential documentation:

  • Genetic confirmation: PHEX gene mutation results or comprehensive XLH genetic panel
  • Laboratory results: Recent serum phosphorus below age-adjusted normal (within 90 days)
  • Specialist attestation: Letter from endocrinologist, nephrologist, or metabolic bone specialist
  • Clinical evidence: Documentation of rickets, bone pain, growth retardation, or osteomalacia
  • Prior therapy records: Evidence of inadequate response or intolerance to oral phosphate plus calcitriol

Additional Requirements for TIO

TIO-specific needs:

  • Elevated FGF23 levels: Laboratory confirmation of excess fibroblast growth factor 23
  • Imaging studies: CT, MRI, or PET scans showing unresectable or unlocatable tumor
  • Clinical symptoms: Documentation of bone pain, fractures, or muscle weakness
  • Age verification: Patient must be ≥2 years old for TIO indication
Tip: Free genetic testing may be available through Kyowa Kirin's support program. Contact them directly to verify eligibility.

ICD-10 Codes to Include

  • XLH: E83.30 (Disorder of phosphate metabolism, unspecified)
  • TIO: M83.8 (Other adult osteomalacia) or M83.1 (Adult hypophosphatemic osteomalacia)

Submit Your Prior Authorization Request

Submission Methods

Fastest options (recommended):

  1. Cigna Provider Portal: Log in at Cigna.com
  2. CoverMyMeds: Electronic submission platform
  3. Accredo direct: Call 800-803-2523 for specialty pharmacy coordination

Alternative method:

  • Fax: 855-840-1678 (include cover sheet with patient ID and urgency level)

Clean Request Packet Checklist

✅ Current prior authorization form (verify 2024/2025 date)
✅ Complete patient demographics and insurance information
✅ Prescriber details with NPI number and specialty
✅ Diagnosis code (E83.30 for XLH, M83.8/M83.1 for TIO)
✅ Genetic test results or family history documentation
✅ Recent lab values (serum phosphorus, calcium, creatinine)
✅ Clinical notes showing symptoms and disease impact
✅ Prior therapy documentation with dates and outcomes
✅ Specialist letter confirming medical necessity
✅ Dosing rationale based on patient weight

Follow-Up and Tracking

When to Call Cigna

Standard timeline: Call if no response after 72 hours for standard requests, 24 hours for urgent requests.

Contact numbers:

  • Provider services: 800-882-4462
  • Member services: 800-244-6224
  • Accredo coordination: 800-803-2523

Sample Follow-Up Script

"I'm calling to check the status of a prior authorization request for Crysvita (burosumab) submitted [date] for patient [name], member ID [number]. The request was for [XLH/TIO] with reference number [if available]. Can you provide the current status and any additional requirements?"

Document everything: Keep records of call dates, representative names, reference numbers, and any additional requests.

Understanding Timelines in Georgia

Standard Review Process

Request Type Cigna Decision Timeline Georgia Requirements
Standard PA 72 hours 30 days maximum
Urgent/Expedited 24 hours 72 hours maximum
Internal Appeal 30 days 30 days required
External Review N/A (state process) 30 business days

Source: Georgia Department of Insurance

What Speeds Decisions

Faster approvals happen when:

  • All required documents are included initially
  • Genetic testing clearly confirms XLH diagnosis
  • Specialist provides detailed medical necessity letter
  • Prior therapy failures are well-documented
  • Request is submitted electronically

If You Need More Information

Handling Medical Necessity Questions

Common requests from Cigna:

  • Additional clinical notes from specialist visits
  • More detailed prior therapy documentation
  • Current medication list (to confirm no contraindicated drugs)
  • Recent imaging studies for TIO cases

Literature to Include

Authoritative sources:

  • FDA prescribing information
  • International consensus guidelines for XLH management
  • Peer-reviewed studies on Crysvita efficacy
  • Professional society recommendations (Endocrine Society, ASBMR)
Note: Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals by identifying the specific denial basis and drafting point-by-point rebuttals aligned to each plan's own rules. Their platform pulls the right citations and weaves them into appeals with required clinical facts.

If Your Request is Denied

Common Denial Reasons & Fixes

Denial Reason How to Overcome Required Documentation
Lack of genetic confirmation Submit PHEX mutation results Genetic testing report
Insufficient clinical evidence Provide detailed specialist notes Clinical documentation of symptoms
No monitoring plan Include phosphorus monitoring schedule Detailed follow-up plan
Contraindicated medications Show current med list Proof of discontinuing phosphate/vitamin D
Step therapy requirement Request exception with medical rationale Specialist letter explaining why alternatives won't work

Georgia Appeals Process

Internal appeals (first step):

  • Deadline: 180 days from denial date
  • Timeline: Cigna must decide within 30 days
  • How to file: Submit appeal form with additional documentation

External review (if internal appeals fail):

  • Deadline: 60 days from final internal denial
  • Cost: Free to consumers
  • Process: File with Georgia Department of Insurance
  • Timeline: 30 business days for decision
  • Result: Binding on Cigna if overturned

Contact for help: Georgia DOI Consumer Services at 1-800-656-2298

Peer-to-Peer Review Request

If denied, request a peer-to-peer review where your specialist can speak directly with Cigna's medical director:

"I'm requesting a peer-to-peer review for the denied Crysvita prior authorization. Please schedule a call between Dr. [name] and your medical director to discuss the medical necessity for this patient with confirmed XLH."

Renewal and Re-Authorization

When to Submit

Timing is critical:

  • Submit renewal requests 30-45 days before current authorization expires
  • Don't wait for prescription refill denial
  • Calendar reminders help avoid treatment gaps

Documentation for Renewal

Evidence of treatment response:

  • Updated serum phosphorus levels showing improvement
  • Clinical notes documenting reduced bone pain or improved mobility
  • Growth velocity improvements in pediatric patients
  • Reduced fracture risk or healing of existing fractures
  • Specialist assessment of continued medical necessity

Quick Reference Checklist

Before Calling Cigna

□ Have member ID and group number ready
□ Know the prescriber's name and NPI
□ Have denial letter or reference number available
□ Prepare specific questions about missing requirements

Required Documents

□ Genetic testing results (PHEX mutation for XLH)
□ Recent serum phosphorus lab (within 90 days)
□ Specialist letter confirming diagnosis
□ Prior therapy documentation
□ Current medication list
□ Clinical notes showing symptoms

Appeal Deadlines (Georgia)

□ Internal appeal: 180 days from denial
□ External review: 60 days from final internal denial
□ Keep copies of all submissions

Frequently Asked Questions

How long does Cigna prior authorization take for Crysvita in Georgia? Standard requests are reviewed within 72 hours, urgent requests within 24 hours. Complete documentation speeds the process significantly.

What if Crysvita is non-formulary on my plan? You can request a formulary exception by providing medical necessity documentation and specialist attestation that formulary alternatives are inappropriate.

Can I request an expedited appeal in Georgia? Yes, if your doctor certifies that delay would seriously jeopardize your health. Expedited appeals must be decided within 72 hours.

Does step therapy apply if I've tried alternatives outside Georgia? Documentation of prior therapy failures from any location should satisfy step therapy requirements. Include detailed records of what was tried and why it failed.

What copay assistance is available for Crysvita? Kyowa Kirin offers the Ultracare program that may reduce copays to $0 for eligible commercially insured patients. Medicare/Medicaid patients have limited manufacturer assistance options.

How do I file an external review with Georgia DOI? Contact Georgia Department of Insurance at 1-800-656-2298 or submit the external review application online. You must file within 60 days of your final internal appeal denial.

What happens if external review approves my Crysvita coverage? The decision is binding on Cigna—they must cover the medication according to the external reviewer's determination.

Can Counterforce Health help with my Crysvita appeal? Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into targeted appeals by analyzing denial letters and plan policies to create evidence-backed rebuttals.

Sources & Further Reading

Disclaimer: This guide provides general information about insurance coverage and appeals processes. It is not medical advice. Always consult with your healthcare provider about treatment decisions and verify current requirements with your insurance plan. For personalized assistance with appeals, contact the Georgia Department of Insurance Consumer Services Division at 1-800-656-2298.

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