By Counterforce Health Team in Kesimpta (ofatumumab) —

How to Get Kesimpta (Ofatumumab) Covered by Cigna in Georgia: Complete Coding, Prior Authorization, and Appeal Guide

Quick Answer: Getting Kesimpta Covered by Cigna in Georgia

Kesimpta (ofatumumab) requires prior authorization from Cigna in Georgia. The fastest path: Your neurologist submits a PA request with ICD-10 code G35 (Multiple Sclerosis), documented hepatitis B screening, and evidence of failed first-line DMTs. If denied, you have 180 days to appeal internally, then 60 days for external review through Georgia's Department of Insurance. First step today: Ask your doctor to check Cigna's formulary and start gathering your prior therapy records.

Table of Contents

  1. Coding Basics: Medical vs. Pharmacy Benefit
  2. ICD-10 Mapping for Kesimpta Coverage
  3. Product Coding: HCPCS, J-Codes, and NDC Numbers
  4. Clean Prior Authorization Request Anatomy
  5. Frequent Coding and Billing Pitfalls
  6. Verification with Cigna Resources
  7. Appeals Playbook for Georgia
  8. Quick Audit Checklist

Coding Basics: Medical vs. Pharmacy Benefit

Kesimpta is almost always covered under the pharmacy benefit, not the medical benefit, because it's a self-administered subcutaneous injection. This distinction affects how you code and bill for the medication.

Pharmacy Benefit Path (Most Common):

  • Use NDC codes for billing
  • Claims processed through Express Scripts/Accredo
  • Prior authorization required
  • Monthly quantity limits apply

Medical Benefit Path (Rare):

  • Only when administered in clinical setting
  • Use HCPCS J-codes (unclassified codes)
  • Most claims rejected unless specific circumstances
Note: According to Cigna's specialty pharmacy policies, self-administered specialty drugs like Kesimpta are typically managed through their pharmacy benefit with Express Scripts.

ICD-10 Mapping for Kesimpta Coverage

Primary ICD-10 Code: G35 (Multiple Sclerosis)

Your documentation must specify that the patient has a relapsing form of MS. Cigna requires evidence of one of these subtypes:

MS Subtype Documentation Keywords Coverage Status
Clinically Isolated Syndrome (CIS) "First demyelinating event," "high risk for MS" ✅ Covered
Relapsing-Remitting MS (RRMS) "Relapses," "remissions," "disease activity" ✅ Covered
Active Secondary Progressive MS "SPMS with relapses," "gadolinium enhancement" ✅ Covered
Primary Progressive MS "PPMS," "steady progression" ❌ Not covered

Supporting Documentation Words:

  • "Relapsing course"
  • "MRI showing new lesions"
  • "Gadolinium-enhancing lesions"
  • "Recent relapse with recovery"

According to Cigna's Kesimpta coverage policy, the diagnosis must be clearly documented as a relapsing form of MS.

Product Coding: HCPCS, J-Codes, and NDC Numbers

NDC Codes (Pharmacy Benefit)

Primary NDC: 0078-1007-68 (Sensoready pen, 20 mg/0.4 mL)

Additional NDCs:

  • 0078-0669-13
  • 0078-0669-61
  • 0078-0690-61

HCPCS J-Codes (Medical Benefit - Rare)

Since Kesimpta doesn't have a specific J-code, use:

  • J3490 (Unclassified drugs)
  • J3590 (Unclassified biologics)
  • C9399 (Unclassified drugs or biologicals)

Always specify "Kesimpta (ofatumumab)" in documentation when using unclassified codes.

Units Calculation

  • Standard dose: 20 mg per injection
  • Loading phase: Weeks 0, 1, 2 (3 units first month)
  • Maintenance: Every 4 weeks (1 unit per month)
Tip: Cigna's quantity limits typically allow one 20 mg injection per month after the loading phase. Verify current limits through their prior authorization resources.

Clean Prior Authorization Request Anatomy

Essential Components

1. Patient Information

  • Name, DOB, Cigna member ID
  • ICD-10: G35 with relapsing MS documentation

2. Prescriber Requirements

  • Must be neurologist or MS specialist
  • Include NPI and credentials

3. Clinical Documentation

  • Hepatitis B screening results (required)
  • Prior DMT failures with specific details:
    • Drug names and dates
    • Duration of treatment
    • Reason for discontinuation
    • Adverse events with dates

4. Dosing Information

  • Loading: 20 mg weeks 0, 1, 2
  • Maintenance: 20 mg every 4 weeks
  • Administration: Subcutaneous self-injection

Sample Request Structure

Patient: [Name], DOB: [Date], Member ID: [Number]
Diagnosis: Multiple Sclerosis (ICD-10: G35) - Relapsing-Remitting type
Prescriber: Dr. [Name], Neurologist, NPI: [Number]

Prior Therapies:
- Glatiramer acetate 20mg: 01/2023-06/2023, discontinued due to injection site reactions
- Dimethyl fumarate: 07/2023-12/2023, discontinued due to GI intolerance

Hepatitis B Status: Negative HBsAg, HBcAb on [date]
Requested: Kesimpta 20mg loading doses weeks 0,1,2, then monthly maintenance

Frequent Coding and Billing Pitfalls

Common Mistakes

1. Wrong Benefit Category

  • ❌ Billing medical benefit for self-administered doses
  • ✅ Use pharmacy benefit for home injections

2. Missing Hepatitis B Documentation

  • ❌ Submitting PA without HBV screening
  • ✅ Include lab results showing negative HBsAg/HBcAb

3. Overlapping DMT Therapy

  • ❌ Not documenting discontinuation of prior DMT
  • ✅ Show clear treatment gaps and transition plan

4. Unit Conversion Errors

  • ❌ Billing for wrong quantities during loading phase
  • ✅ 3 units month 1, then 1 unit monthly

5. Non-Specialist Prescriber

  • ❌ Primary care physician submitting request
  • ✅ Neurologist or MS specialist required

Documentation Red Flags

  • Vague MS subtype ("MS" without specifying relapsing)
  • Missing vaccination records
  • Concurrent DMT use
  • Incomplete prior therapy history

Verification with Cigna Resources

Pre-Submission Checklist

1. Check Current Formulary Status

2. Confirm Prior Authorization Requirements

3. Validate Specialty Pharmacy Network

  • Confirm Express Scripts/Accredo requirements
  • Verify patient's preferred pharmacy is in-network

4. Review Quantity Limits

  • Standard: 1 injection per month after loading
  • Loading phase: 3 injections first month

Cross-Reference Tools

  • Cigna provider portal for real-time eligibility
  • Express Scripts formulary for specialty drugs
  • Georgia DOI website for appeals information

Appeals Playbook for Georgia

Internal Appeal Process

Timeline: Must file within 180 days of denial

Step 1: First-Level Internal Appeal

  • Submit written appeal to Cigna
  • Include new clinical documentation
  • Decision within 60 days

Step 2: Expedited Appeal (if urgent)

  • For immediate medical need
  • Decision within 72 hours for pharmacy
  • 24 hours for expedited requests

Georgia External Review

Eligibility: After exhausting internal appeals

Timeline:

  • File within 60 days of final internal denial
  • Standard review: 45 days
  • Expedited review: 72 hours

How to File:

  1. Contact Georgia Department of Insurance: 1-800-656-2298
  2. Submit external review application
  3. Include all denial letters and medical records

Cost: Free for consumers in Georgia

Important: Georgia's external review is binding on Cigna if the decision favors coverage.

When to Escalate

Contact Georgia DOI Consumer Services if:

  • Cigna doesn't respond within required timeframes
  • You need help with the external review process
  • You suspect procedural violations

Quick Audit Checklist

Pre-Submission Review

Patient Eligibility

  • Age 18+ confirmed
  • Relapsing MS diagnosis documented
  • ICD-10 code G35 with subtype specified

Clinical Requirements

  • Neurologist/MS specialist prescriber
  • Hepatitis B screening completed and documented
  • Prior DMT failures detailed with dates and reasons
  • No overlapping DMT therapy

Coding Accuracy

  • Correct NDC for pharmacy benefit (0078-1007-68)
  • Proper units: 3 for loading, 1 monthly maintenance
  • Appropriate HCPCS if medical benefit (J3490/J3590)

Documentation Complete

  • Medical necessity letter from prescriber
  • Lab results attached
  • Prior therapy records included
  • Dosing schedule specified

Submission Details

  • Correct Cigna PA form used
  • All required fields completed
  • Supporting documents attached
  • Submission deadline met

Coverage Support and Resources

Counterforce Health specializes in turning insurance denials into successful appeals by analyzing denial letters, plan policies, and clinical notes to create targeted, evidence-backed rebuttals. Their platform identifies the specific denial basis and drafts point-by-point responses aligned to each plan's rules, pulling the right citations and clinical facts needed for approval.

Manufacturer Support

  • Novartis MS One-to-One: Coverage support and copay assistance
  • Patient assistance programs: For eligible uninsured patients
  • Prior authorization support: Clinical specialists available

State Resources

  • Georgia Department of Insurance: 1-800-656-2298
  • Georgians for a Healthy Future: Consumer assistance nonprofit
  • Georgia Legal Services Program: For Medicaid appeals

Frequently Asked Questions

How long does Cigna prior authorization take in Georgia? Standard PA decisions are made within 72 hours for pharmacy requests. Expedited reviews for urgent medical needs are completed within 24 hours.

What if Kesimpta is non-formulary on my plan? You can request a formulary exception with clinical justification. Your doctor must demonstrate medical necessity and why formulary alternatives aren't appropriate.

Can I request an expedited appeal? Yes, if you have an urgent medical need. Expedited appeals are decided within 72 hours for standard cases, 24 hours for truly urgent situations.

Does step therapy apply if I've failed DMTs outside Georgia? Yes, prior therapy failures from any state count toward step therapy requirements. Include all medical records documenting these failures.

What happens if my external review is denied? Georgia's external review is the final administrative step. Further disputes would require legal action, though this is rare when proper documentation is provided.

From Our Advocates

We've seen many Kesimpta approvals succeed when the initial request includes comprehensive hepatitis B screening documentation and detailed prior therapy histories. One common pattern: patients who document specific adverse events (with dates) from previous DMTs have higher approval rates than those with vague "intolerance" claims. Always be as specific as possible about why each prior therapy failed.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage policies and requirements may vary by plan and change over time. Always verify current requirements with Cigna and consult with your healthcare provider for medical decisions. For personalized assistance with appeals, consider working with Counterforce Health or other qualified patient advocacy services.

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