By Counterforce Health Team in iLink® (corneal cross-linking system) —

How to Get iLink® Corneal Cross-Linking Covered by Cigna in Washington: Complete Prior Authorization Guide

Answer Box: Getting iLink® Covered by Cigna in Washington

To get iLink® corneal cross-linking covered by Cigna in Washington, you need prior authorization demonstrating progressive keratoconus through serial corneal topography. Your ophthalmologist submits documentation via Cigna's provider portal showing disease progression, failed conservative treatments, and medical necessity. Standard approval takes 5-7 business days; expedited review available for urgent cases within 72 hours. If denied, Washington's external review process through an Independent Review Organization (IRO) provides binding oversight within 120 days of the final internal denial.

First step today: Schedule an eye exam with corneal imaging and request copies of all previous topography results to document progression.

Table of Contents

Understanding iLink® Coverage Requirements

iLink® is the only FDA-approved corneal cross-linking system in the United States, manufactured by Glaukos for treating progressive keratoconus and corneal ectasia. Cigna requires prior authorization for this procedure, which typically costs $2,500-$4,000 per eye without insurance coverage.

Coverage at a Glance

Requirement What It Means Documentation Needed Source
Prior Authorization Pre-approval required before procedure Ophthalmologist's letter with progression data Cigna PA Requirements
Progressive Keratoconus Disease must be actively worsening Serial corneal topography showing measurable changes FDA iLink® approval criteria
Failed Conservative Treatment Lenses/other options tried first Documentation of lens intolerance or inadequate vision Medical necessity standards
In-Network Provider Procedure at participating facility Verify provider status via Cigna directory Plan benefits
ICD-10 Diagnosis Code Specific keratoconus coding H18.6xx series codes Billing requirements

Prior Authorization Process

Step-by-Step: Fastest Path to Approval

  1. Gather Documentation (Patient/Clinic)
    • Previous corneal topography results spanning 6+ months
    • Contact lens fitting records showing intolerance
    • Visual acuity measurements over time
    • Timeline: 1-2 weeks to collect
  2. Schedule Comprehensive Eye Exam (Patient)
    • Current corneal imaging and topography
    • Complete keratoconus staging
    • Submit via Cigna provider portal
    • Timeline: Same day
  3. Provider Submits PA Request (Ophthalmologist)
    • Via CignaforHCP.com or CoverMyMeds platform
    • Include all required documentation
    • Request expedited review if vision rapidly declining
    • Timeline: 5-7 business days standard; 72 hours expedited
  4. Track Application Status (Patient/Clinic)
    • Use myCigna app or provider portal
    • Follow up if no response within timeline
    • Timeline: Real-time updates

Medical Necessity Letter Checklist

Your ophthalmologist's prior authorization letter must include:

  • Patient Information: Full name, date of birth, Cigna member ID, group number
  • Diagnosis: Keratoconus with appropriate ICD-10 code (e.g., H18.601 for right eye)
  • Progression Documentation: Serial topography showing measurable worsening over time
  • Failed Treatments: History of contact lens trials, glasses, or other interventions
  • Clinical Rationale: Why iLink® is medically necessary and time-sensitive
  • Procedure Details: CPT code 0402T for corneal cross-linking
  • Provider Credentials: Board certification and experience with keratoconus
Tip: Request a peer-to-peer review if initially denied. Medical necessity denials have an 80-85% overturn rate when specialists speak directly with Cigna's medical reviewers.

Washington State Appeal Rights

Washington provides strong consumer protections for insurance denials under RCW 48.43.535, giving you multiple levels of appeal beyond Cigna's internal process.

Internal Appeals Process

First Level Internal Appeal:

  • Deadline: 180 days from denial notice
  • Response Time: 30 days for medical necessity appeals
  • Submission: Cigna National Appeals Unit, P.O. Box 188011, Chattanooga, TN 37422
  • Required Elements: Member ID, claim number, medical justification, supporting documentation

Expedited Appeals:

  • Timeline: 72 hours for urgent medical situations
  • Criteria: Delay would seriously jeopardize health or vision
  • Process: Call 1-800-88-CIGNA and explicitly request "expedited appeal"

Washington's External Review Protection

If Cigna denies your internal appeal, Washington law provides access to an Independent Review Organization (IRO) for binding external review.

Key Benefits:

  • Independent Decision: Takes the decision out of Cigna's hands
  • Binding Result: If IRO approves, Cigna must cover the procedure
  • No Cost: Free to patients
  • Expert Review: Corneal specialists review your case

Filing Requirements:

Common Denial Reasons & Solutions

Denial Reason How to Overturn Documentation to Include
Insufficient progression documentation Resubmit with serial topography measurements Keratometry readings showing steepening over 6+ months
Does not meet medical necessity Strengthen clinical rationale Cite FDA approval, vision loss without treatment
Experimental/investigational Challenge with FDA approval status Reference FDA approval letter for iLink® system
Out-of-network provider Request network exception Document lack of in-network corneal specialists
Missing prior authorization Submit retroactive PA if applicable Complete medical necessity documentation

Scripts for Common Situations

Patient Phone Script for Cigna: "I'm calling about prior authorization for iLink® corneal cross-linking for progressive keratoconus. My member ID is [number]. Can you confirm the status and let me know what additional documentation might be needed?"

Clinic Staff Script for Peer-to-Peer: "I'm requesting a peer-to-peer review for [patient name] regarding denial of iLink® corneal cross-linking. The patient has documented progressive keratoconus with serial topography showing significant steepening. When can we schedule a call with your medical director?"

Step Therapy Protections

Washington state provides protections against inappropriate step therapy requirements under RCW 48.43.515. Your physician can request a medical exception if:

  • You previously tried required treatments and they were ineffective
  • The preferred therapy would cause adverse reactions
  • You have an urgent condition where delay risks serious harm
  • Your physician documents medical necessity for the specific treatment

Exception Timeline: 72 hours for urgent requests; 5 business days for standard requests.

External Review Process

When to Request External Review

Consider external review if Cigna:

  • Denies coverage citing medical necessity
  • Claims the procedure is experimental (despite FDA approval)
  • Requires inappropriate step therapy
  • Fails to respond within required timelines

How to File

  1. Complete Internal Appeals First: Exhaust Cigna's internal process or wait for timeline expiration
  2. Submit Request Within 120 Days: File with Cigna, who notifies the Washington OIC
  3. Include Supporting Documentation: Any new evidence not previously submitted
  4. Track Your Case: The assigned IRO will contact you directly

Timeline: Standard external review decisions come within 15-20 days; expedited reviews within 72 hours for urgent cases.

From our advocates: "We've seen Washington patients successfully overturn iLink® denials through external review by emphasizing the progressive nature of keratoconus and the lack of alternative FDA-approved treatments. The key is comprehensive documentation showing disease progression and failed conservative management."

Cost Considerations

With Insurance: Copay/coinsurance applies after prior authorization approval Without Authorization: $2,500-$4,000 per eye out-of-pocket Manufacturer Support: Check with Glaukos for potential patient assistance programs Payment Plans: Many ophthalmology practices offer financing options

FAQ

How long does Cigna prior authorization take in Washington? Standard review takes 5-7 business days; expedited review for urgent cases takes 72 hours. Cigna must respond within these timeframes or approval is automatic.

What if iLink® is not on Cigna's formulary? iLink® is a medical procedure, not a prescription drug, so formulary status doesn't apply. Coverage depends on medical necessity and prior authorization approval.

Can I request an expedited appeal? Yes, if delay in treatment would seriously jeopardize your vision or health. Call 1-800-88-CIGNA and explicitly request expedited review with clinical justification.

Does step therapy apply to corneal cross-linking? Step therapy typically applies to medications, not procedures. However, Cigna may require documentation of failed conservative treatments like contact lenses.

What happens if my employer plan is self-funded? Self-funded ERISA plans may not be subject to Washington state protections. However, many voluntarily follow similar appeal processes. Contact the U.S. Department of Labor for ERISA plan appeals.

How do I find an in-network corneal specialist? Use Cigna's provider directory online or call member services. If no in-network specialists are available, request a network exception for out-of-network coverage.

What documentation proves keratoconus progression? Serial corneal topography showing measurable steepening over time (typically 6+ months), along with declining visual acuity despite optimal correction.

Can I appeal if treatment was already performed? You can request retroactive prior authorization in some cases, but it's much more difficult. Always seek pre-authorization when possible.

Getting Additional Help

Counterforce Health specializes in turning insurance denials into successful appeals by creating targeted, evidence-backed rebuttals that align with each plan's specific requirements. Their platform analyzes denial letters and plan policies to draft point-by-point responses with the right clinical evidence and procedural requirements, helping patients navigate complex prior authorization and appeals processes more effectively.

For additional support with your Cigna appeal in Washington:

  • Washington Office of Insurance Commissioner: 1-800-562-6900 for consumer advocacy assistance
  • Cigna Member Services: 1-800-88-CIGNA for plan-specific questions
  • Coverage Rights: Free resources and template letters for Washington residents

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 about treatment decisions and contact the Washington Office of Insurance Commissioner or a qualified attorney for specific legal guidance regarding insurance appeals.

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