By Counterforce Health Team in Eylea / Lucentis (aflibercept / ranibizumab) —

How to Get Eylea or Lucentis Covered by Cigna in Illinois: Appeals Guide with Forms and Timelines

Quick Answer: Getting Eylea or Lucentis Approved by Cigna in Illinois

Cigna requires prior authorization for Eylea (aflibercept) and Lucentis (ranibizumab) with step therapy requiring bevacizumab trial first. Submit PA requests through CoverMyMeds or call 1-800-882-4462. If denied, you have 180 days to appeal internally, then 4 months for Illinois external review. With 86% appeal success rates for Cigna Medicare Advantage and strong Illinois patient protections, most denials can be overturned with proper documentation.

First step today: Check if your prescriber submitted step therapy documentation showing bevacizumab failure or contraindication through Express Scripts PA portal.

Table of Contents

  1. Read Your Denial Letter
  2. Common Fixable Causes
  3. First-Level Appeal Process
  4. Peer-to-Peer Review Strategy
  5. Illinois External Review Rights
  6. Appeal Letter Templates
  7. Tracking and Escalation
  8. Medical Necessity Boosters
  9. If Appeals Fail: Next Steps
  10. FAQ

Read Your Denial Letter

Your Cigna denial letter contains critical information for your appeal strategy. Look for these key elements:

Denial Reason Codes to Identify:

  • Prior authorization required: Need PA submission through Express Scripts
  • Step therapy not met: Must try bevacizumab first per Express Scripts formulary
  • Not medically necessary: Clinical criteria not met
  • Quantity/frequency limits: Exceeds approved dosing schedule
  • Non-formulary: Drug not on preferred list

Critical Deadlines:

  • Internal appeals: 180 calendar days from denial date
  • External review: 4 months after final internal denial (Illinois-specific)
  • Expedited appeals: Available for urgent cases (72-hour response)
Note: Illinois has a shorter external review window than many states—don't wait to file after internal appeals are exhausted.

Common Fixable Causes

Many Cigna denials can be resolved without formal appeals by addressing documentation gaps:

Missing Step Therapy Documentation

The Problem: Cigna requires bevacizumab trial before approving Eylea/Lucentis for wet AMD or diabetic macular edema.

The Fix: Submit evidence of:

  • Bevacizumab trial with dates and response
  • Contraindications (pregnancy, recent surgery)
  • Intolerance or inadequate response
  • Provider rationale for skipping step therapy

Incomplete Medical Necessity

The Problem: Missing clinical documentation supporting treatment need.

The Fix: Include comprehensive records showing:

  • Confirmed diagnosis with ICD-10 codes
  • Visual acuity measurements and OCT imaging
  • Treatment history and outcomes
  • Functional impact on daily activities

Coverage Requirements at a Glance

Requirement Cigna Criteria Where to Find Source
Prior Authorization Required for both drugs Express Scripts portal PA Requirements
Step Therapy Bevacizumab trial first Formulary guidelines Cigna Formulary
Diagnosis Codes Wet AMD, DME, DR Medical policy Coverage Policies
Frequency Limits Monthly loading, then extend Clinical guidelines AAO Guidelines
Appeal Deadline 180 days internal Member handbook Appeals Process

First-Level Appeal Process

Step 1: Gather Required Documentation

Before submitting your appeal, collect:

  • Original denial letter with reference numbers
  • Complete medical records from treating ophthalmologist
  • OCT scans and visual acuity measurements
  • Treatment timeline showing prior therapies tried
  • Letter of medical necessity (see clinician template below)
  • Published guidelines supporting treatment choice

Step 2: Submit Through Correct Channel

For Commercial Plans:

  • Online: Cigna Provider Portal
  • Fax: Use appeal form fax number (verify current number)
  • Mail: Include appeal form and supporting documents

For Medicare Advantage:

  • Must use Medicare-specific appeal process
  • 65-day deadline from denial notice
  • Can request expedited review for urgent cases

Step 3: Request Peer-to-Peer Review

Contact Cigna immediately to schedule peer-to-peer review:

  • Call 1-800-88-CIGNA (Provider Services)
  • Request medical director review
  • 80-85% success rate for these calls
  • Often resolves denial without full appeal process

Clinician Corner: Medical Necessity Letter Checklist

Healthcare providers should include these elements in letters of medical necessity:

Patient Information:

  • Confirmed diagnosis with ICD-10 codes
  • Visual acuity measurements (baseline and current)
  • OCT findings showing retinal pathology
  • Functional impact on patient's daily activities

Treatment Rationale:

  • Why bevacizumab is inappropriate or failed
  • Specific contraindications if applicable
  • Expected treatment response timeline
  • Monitoring plan and follow-up schedule

Evidence Base:

From our advocates: We've seen appeals succeed when providers include specific visual acuity improvements expected (e.g., "anticipated 2-line improvement based on clinical trials") and concrete functional goals like "return to driving safely." Payers respond well to measurable outcomes tied to quality of life.

Illinois External Review Rights

Illinois provides strong patient protections through the Health Carrier External Review Act. After exhausting Cigna's internal appeals, you can request independent review.

External Review Process

Eligibility: Available after final internal appeal denial for medical necessity determinations.

Timeline: Must file within 4 months of final internal denial (shorter than most states).

How to File:

  1. Complete Illinois External Review Form
  2. Submit to Illinois Department of Insurance
  3. Include denial letters and medical records
  4. Request expedited review if urgent

Review Process:

  • Independent physician reviewer assigned
  • Binding decision on Cigna
  • No cost to patient
  • Typically completed within 45 days

Contact for Help: Illinois Department of Insurance at (877) 527-9431

Common Denial Reasons & How to Overturn Them

Denial Reason Required Documentation Success Strategy
Step therapy not met Bevacizumab trial records or contraindication Document specific failure or medical reason to skip
Not medically necessary Clinical notes, imaging, VA scores Quote AAO guidelines showing first-line recommendation
Quantity limits exceeded Treatment protocol, response monitoring Show medical need for current frequency
Experimental/investigational FDA labeling, published studies Demonstrate FDA-approved indication
Non-formulary status Formulary exception request Document formulary alternatives tried/failed

Appeal Letter Template

Patient Appeal Letter Structure

Header Information:

  • Member name and ID number
  • Policy number and group number
  • Denial reference number and date
  • Requested action (approval of Eylea/Lucentis)

Opening Paragraph: "I am writing to formally appeal the denial of coverage for [Eylea/Lucentis] dated [denial date]. This medication is medically necessary for my [wet AMD/diabetic macular edema] as prescribed by my retina specialist."

Medical Justification:

  • Diagnosis with ICD-10 code
  • Visual acuity measurements showing impairment
  • Prior treatment attempts and outcomes
  • Contraindications to step therapy if applicable

Supporting Evidence:

  • Physician letter of medical necessity
  • OCT imaging results
  • Treatment guidelines supporting therapy choice
  • Published studies demonstrating efficacy

Closing: "Based on the medical evidence provided, I respectfully request approval of [drug name] as medically necessary treatment. I am available to provide additional information if needed."

Tracking Your Appeal

Document Everything:

  • Appeal submission date and method
  • Confirmation numbers received
  • All communications with Cigna
  • Deadlines for each appeal level
  • Supporting documents submitted

Follow Up Schedule:

  • Week 1: Confirm receipt of appeal
  • Week 2: Check processing status
  • Week 3: Request expedited review if no response
  • Week 4: Contact Illinois DOI if deadline missed

Escalation Triggers:

  • Missed response deadlines
  • Denial of peer-to-peer review
  • Procedural violations
  • Request for additional information not in original denial

Medical Necessity Win-Rate Boosters

Strengthen Your Case With These Elements

Clinical Documentation:

  • Baseline and current visual acuity measurements
  • OCT scans showing anatomical changes
  • Photography documenting retinal pathology
  • Functional vision assessments

Treatment History:

  • Detailed record of all prior therapies
  • Specific reasons for discontinuation
  • Duration of treatment trials
  • Quantified response or lack thereof

Guideline Citations:

Quality of Life Impact:

  • Driving limitations due to vision loss
  • Work or daily activity impairment
  • Fall risk or safety concerns
  • Social isolation due to visual limitations

If Appeals Fail: Alternative Options

Manufacturer Support Programs

Eylea (Regeneron):

  • Copay assistance program
  • Patient assistance for uninsured
  • Prior authorization support services

Lucentis (Genentech):

  • Copay savings program
  • Access solutions for coverage gaps
  • Clinical support programs

Alternative Coverage Strategies

Formulary Exception Requests:

  • Request non-formulary coverage
  • Demonstrate medical need vs. alternatives
  • Submit comparative effectiveness data

Site of Care Considerations:

  • Hospital outpatient vs. ASC administration
  • Medical vs. pharmacy benefit coverage
  • Buy-and-bill reimbursement options

State and Federal Resources

Illinois Department of Insurance:

  • Consumer complaint process
  • Coverage dispute resolution
  • External review coordination

Medicare Rights:

  • Medicare Part B coverage appeals
  • Administrative Law Judge hearings
  • Federal court review options

Counterforce Health specializes in turning insurance denials into successful appeals by analyzing denial letters, payer policies, and clinical documentation to create targeted, evidence-backed rebuttals. Our platform helps patients, clinicians, and pharmacies navigate complex prior authorization requirements and appeal processes with higher success rates.

For more information about appeal strategies and coverage assistance, visit www.counterforcehealth.org.

FAQ

How long does Cigna prior authorization take for Eylea/Lucentis in Illinois? Standard PA decisions typically take 5-7 business days. Expedited reviews for urgent cases must be completed within 72 hours per Illinois regulations.

What if Eylea/Lucentis is non-formulary on my Cigna plan? You can request a formulary exception by demonstrating medical necessity and failure of formulary alternatives. Include comparative effectiveness data and contraindications to preferred drugs.

Can I request expedited appeal if my vision is worsening? Yes. Illinois allows expedited appeals for urgent medical conditions. Your retina specialist must certify that delays would seriously jeopardize your health or vision.

Does step therapy apply if I've failed bevacizumab outside Illinois? Yes, but you must provide documentation from your previous provider showing the trial, duration, and reason for discontinuation. Out-of-state records are accepted.

What happens if Cigna misses appeal deadlines? Contact the Illinois Department of Insurance at (877) 527-9431 to file a complaint. Missed deadlines can result in automatic approval or penalties for the insurer.

How much does external review cost in Illinois? External review is free for consumers. Illinois insurers pay the cost of independent physician reviews, and there are no filing fees for patients.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage decisions vary by individual plan and medical circumstances. Always consult with your healthcare provider and insurance plan for specific coverage requirements and appeal procedures. For personalized assistance with insurance appeals, contact qualified healthcare advocates or the Illinois Department of Insurance consumer helpline.

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