By Counterforce Health Team in Crysvita (burosumab) —

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

Answer Box: Getting Crysvita Covered by Cigna in Michigan

Eligibility: Patients 6+ months with X-linked hypophosphatemia (XLH) or 2+ years with tumor-induced osteomalacia require genetic testing, specialist attestation, and documented failure of oral phosphate plus active vitamin D therapy.

Fastest Path: Submit prior authorization through Cigna's provider portal with complete documentation including PHEX gene mutation results, recent serum phosphorus levels, and endocrinologist letter. Standard decisions take 5-10 business days.

First Step Today: Contact your prescriber to order genetic testing through the free Kyowa Kirin/Invitae program and schedule specialist consultation if not already completed.

Michigan Appeal Rights: After internal appeal denial, you have 127 days to file external review with Michigan DIFS, which provides binding decisions within 60 days.

Table of Contents

  1. Cigna Prior Authorization Requirements
  2. Medical vs. Pharmacy Benefit Pathways
  3. ICD-10 and Billing Code Documentation
  4. Step-by-Step: Fastest Path to Approval
  5. Common Denial Reasons & How to Fix Them
  6. Michigan Appeals Process
  7. Cost and Patient Support Programs
  8. Frequently Asked Questions

Cigna Prior Authorization Requirements

Crysvita (burosumab) requires prior authorization through Cigna's specialty pharmacy network, typically Accredo. The medication is billed under the medical benefit using HCPCS code J0584, where each billable unit equals 1 mg of medication.

Coverage at a Glance

Requirement What It Means Documentation Needed Timeline
Genetic Testing PHEX gene mutation confirmed Genetic panel report or Invitae results 2-4 weeks
Specialist Attestation Endocrinologist medical necessity letter Provider letter with clinical rationale 1-2 weeks
Laboratory Evidence Serum phosphorus below normal Recent labs within 90 days Same day
Prior Therapy Documentation Failed oral phosphate + calcitriol Clinical notes showing 6+ months trial Varies
Age Requirements XLH: 6+ months; TIO: 2+ years Medical records confirming age Same day

Source: Cigna Crysvita Coverage Policy

Medical vs. Pharmacy Benefit Pathways

Crysvita is administered via subcutaneous injection by healthcare providers and falls under the medical benefit, not pharmacy benefit. This distinction affects your coverage pathway and out-of-pocket costs.

Medical Benefit Coverage

  • Billed using HCPCS code J0584
  • Administered in clinic, infusion center, or home health setting
  • Subject to medical deductible and coinsurance
  • Requires prior authorization through Cigna's medical management

Dosing and Billing Units

Adults: 1 mg/kg body weight (rounded to nearest 10 mg), maximum 90 mg every 4 weeks Pediatric: 0.8 mg/kg body weight (rounded to nearest 10 mg), maximum 90 mg every 2 weeks

For billing purposes, a 70 kg adult receiving 70 mg would generate 70 billable units under J0584.

ICD-10 and Billing Code Documentation

Proper coding supports medical necessity and reduces claim denials. The primary ICD-10 code for X-linked hypophosphatemia is E83.31 (Familial hypophosphatemic rickets).

Supporting Documentation Language

When documenting in medical records, include specific terminology that supports coding:

  • "Confirmed PHEX gene mutation"
  • "Serum phosphorus below age-adjusted normal range"
  • "Failed conventional therapy with oral phosphate supplementation"
  • "Progressive bone deformities consistent with hypophosphatemic rickets"
  • "Elevated or inappropriately normal FGF23 levels"

HCPCS Code Details

  • J0584: Injection, burosumab-twza 1 mg
  • Maximum units per dose: 90 units (90 mg)
  • Frequency: Every 14-28 days depending on age and indication

Step-by-Step: Fastest Path to Approval

1. Confirm Diagnosis and Genetic Testing

Who: Patient and prescriber Timeline: 2-4 weeks if testing needed Action: Order genetic testing through Kyowa Kirin's free program or commercial laboratory to confirm PHEX gene mutation.

2. Gather Required Laboratory Evidence

Who: Prescriber Timeline: Same day if recent labs available Action: Obtain serum phosphorus levels within 90 days showing values below age-adjusted normal range. Include FGF23 levels if available.

3. Document Prior Therapy Failures

Who: Prescriber Timeline: 1-2 weeks to compile records Action: Compile clinical notes demonstrating at least 6 months of oral phosphate plus active vitamin D therapy with inadequate response or intolerance.

4. Obtain Specialist Consultation

Who: Patient Timeline: 2-6 weeks for appointment Action: Schedule consultation with endocrinologist, geneticist, or metabolic bone specialist if not already established.

5. Submit Prior Authorization

Who: Prescriber's office Timeline: 5-10 business days for decision Action: Submit complete prior authorization through Cigna's provider portal including all documentation.

6. Coordinate with Specialty Pharmacy

Who: Patient and prescriber Timeline: 1-2 weeks after approval Action: Work with Accredo to schedule delivery and administration coordination.

7. Monitor and Document Response

Who: Prescriber Timeline: Ongoing monthly for first 3 months Action: Monitor serum phosphorus levels monthly and document clinical response for renewal authorization.

Common Denial Reasons & How to Fix Them

Denial Reason Fix Strategy Required Documentation
Incomplete genetic testing Submit PHEX mutation results Genetic panel report from certified lab
Missing specialist attestation Obtain endocrinologist letter Medical necessity letter with clinical rationale
Insufficient prior therapy documentation Compile treatment history Clinical notes showing 6+ months oral phosphate trial
Contraindicated medications Confirm discontinuation Provider note stating oral phosphate/vitamin D stopped
Age requirements not met Verify patient age Medical records confirming age eligibility
Tip: Cigna often approves requests within 72 hours when complete documentation is submitted electronically through their provider portal.

Michigan Appeals Process

If Cigna denies your initial prior authorization request, Michigan provides robust appeal protections through the Department of Insurance and Financial Services (DIFS).

Internal Appeals with Cigna

Timeline: 180 days from denial date to file Process: Submit appeal through Cigna member portal or by phone Decision timeframe: 15 days standard, 72 hours expedited

Michigan DIFS External Review

Eligibility: After completing Cigna's internal appeal process Filing deadline: 127 days from final internal denial Decision timeline: 60 days standard, 72 hours expedited

How to File External Review

  1. Gather Required Documents
    • Final denial letter from Cigna
    • Clinical evidence supporting medical necessity
    • Specialist evaluations and genetic testing results
  2. Submit Request
  3. Expedited Review Option Available if treating physician certifies in writing that delay would harm patient's health or ability to regain maximum function.
Note: DIFS external review decisions are binding on Cigna if approved. Both patient and insurer receive written notice of the outcome.

Clinician Corner: Medical Necessity Letter Checklist

When preparing medical necessity documentation for Crysvita, include these essential elements:

Clinical Problem Statement

  • Confirmed diagnosis of XLH with genetic testing results
  • Current serum phosphorus levels and trend over time
  • Specific symptoms (bone pain, growth retardation, dental issues)

Prior Treatment Documentation

  • Duration and dosing of oral phosphate supplementation
  • Active vitamin D therapy details and response
  • Reasons for discontinuation (inadequate response, side effects)

Clinical Rationale for Crysvita

  • FDA approval status for patient's specific indication
  • Expected clinical benefits based on pivotal trial data
  • Monitoring plan for serum phosphorus and clinical response

Guideline Support Reference authoritative sources such as:

Cost and Patient Support Programs

Manufacturer Support Programs

Kyowa Kirin Patient Support

  • Copay assistance for eligible commercially insured patients
  • Free genetic testing program
  • Nursing support and injection training
  • Contact: CrysvitaSupport.com

Foundation Assistance

Patient Access Network (PAN) Foundation

  • Provides copay assistance for rare disease medications
  • Income-based eligibility requirements
  • Application available at PANFoundation.org

National Organization for Rare Disorders (NORD)

  • Patient assistance programs for rare disease treatments
  • Advocacy resources and support groups
  • Information at RareDisease.org

Frequently Asked Questions

Q: How long does Cigna prior authorization take for Crysvita in Michigan? A: Standard decisions are made within 5-10 business days. Expedited requests for urgent medical situations are processed within 72 hours.

Q: What if Crysvita is not on Cigna's formulary? A: Request a formulary exception by demonstrating medical necessity and lack of suitable alternatives. Include comparative effectiveness data and specialist attestation.

Q: Can I request an expedited appeal if denied? A: Yes, if your treating physician certifies that delay would harm your health. Both Cigna and Michigan DIFS offer expedited review processes.

Q: Does step therapy apply to Crysvita coverage? A: Yes, Cigna requires documentation of failure or intolerance to oral phosphate plus active vitamin D therapy before approving Crysvita.

Q: What documentation do I need for genetic testing? A: Submit results from PHEX gene mutation testing or comprehensive XLH genetic panel from a certified laboratory. Kyowa Kirin offers free testing through their patient support program.

Q: How often do I need to renew prior authorization? A: Initial approvals are typically for 6 months, with renewals granted for 12-month periods thereafter, subject to continued medical necessity.

Q: What if my appeal to DIFS is denied? A: You have 60 days to seek judicial review in Michigan circuit court. Additional remedies may be available under state or federal law.

Q: Can my doctor file appeals on my behalf? A: Yes, with your written consent, your physician or another authorized representative can file appeals for you with both Cigna and Michigan DIFS.

When to Get Additional Support

For complex appeals involving specialty drugs like Crysvita, consider working with organizations that specialize in insurance coverage advocacy. Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into targeted, evidence-backed appeals by analyzing denial letters, cross-referencing plan policies, and drafting point-by-point rebuttals using FDA labeling, peer-reviewed studies, and specialty guidelines aligned to each payer's specific requirements.

These services can be particularly valuable when facing repeated denials or when navigating complex prior authorization requirements for rare disease treatments that require extensive clinical documentation and regulatory expertise.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage decisions depend on individual circumstances and specific insurance plan terms. Always consult with your healthcare provider and insurance plan directly for personalized guidance. For official Michigan insurance regulations and appeal procedures, visit Michigan.gov/DIFS or call 877-999-6442.

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