By Counterforce Health Team in Kymriah (tisagenlecleucel) —

How to Get Kymriah (tisagenlecleucel) Covered by Cigna in Illinois: Complete Appeals Guide with Forms and Timelines

Answer Box: Getting Kymriah Covered by Cigna in Illinois

Cigna covers Kymriah (tisagenlecleucel) for FDA-approved indications with prior authorization through certified CAR-T centers. Most common path: 1) Submit PA with medical necessity letter documenting CD19+ disease and prior therapy failures, 2) If denied, request peer-to-peer review immediately, 3) File internal appeal within 180 days using Cigna's medical appeal form. Illinois offers external review within 4 months if internal appeals fail. Start with your certified treatment center's financial coordinator—they handle most PA submissions. First step today: Contact your CAR-T center to verify Cigna network status and begin benefits verification.

Table of Contents

  1. Understanding Cigna's Kymriah Coverage
  2. Illinois Certified CAR-T Treatment Centers
  3. Prior Authorization Requirements
  4. Common Denial Reasons & How to Fix Them
  5. Internal Appeals Process
  6. Peer-to-Peer Review Strategy
  7. Illinois External Review Process
  8. Medical Necessity Letter Template
  9. Cost Assistance Options
  10. When to Escalate
  11. FAQ

Understanding Cigna's Kymriah Coverage

Cigna covers Kymriah through its specialty pharmacy benefit (typically Express Scripts/Accredo) for patients meeting FDA-approved indications. The therapy requires prior authorization regardless of your plan type, with coverage limited to Cigna LifeSOURCE certified centers.

Coverage at a Glance

Requirement Details Where to Find It
Prior Authorization Required for all Kymriah infusions Denial letter or provider portal
Formulary Status Specialty tier (varies by plan) Plan formulary document
Site of Care Cigna LifeSOURCE certified centers only Center locator
Age Requirements ≤25 years (ALL); ≥18 years (DLBCL) FDA prescribing information
Step Therapy Document ≥2 prior therapy failures Clinical notes, discharge summaries
Appeals Deadline 180 days from denial notice Cigna appeals policy

Illinois Certified CAR-T Treatment Centers

Only four Illinois facilities are certified for Kymriah administration under the Novartis REMS program:

  • Northwestern Medicine/Lurie Comprehensive Cancer Center (Chicago) - Adult DLBCL and pediatric ALL programs
  • University of Chicago Medicine (Chicago) - Adult and pediatric programs; Patient: (855) 702-8222
  • University of Illinois Hospital (Chicago) - Adult DLBCL and B-cell malignancies
  • Loyola Medicine (Maywood) - Adult CAR-T with complex case management
Tip: Use the official Kymriah Treatment Center Locator to confirm current REMS certification, as the list updates regularly.

Prior Authorization Requirements

Cigna's medical necessity criteria align with FDA labeling but require specific documentation:

For B-cell ALL (≤25 years)

  • CD19-positive disease confirmed by flow cytometry or immunohistochemistry
  • Refractory disease or second/later relapse after standard induction therapy
  • Absolute lymphocyte count ≥500/μL or CD3+ T-cells ≥150/μL
  • ECOG performance status ≤2
  • Documentation of prior therapies including rituximab and anthracycline

For DLBCL (≥18 years)

  • CD19-positive large B-cell lymphoma
  • Relapsed or refractory after ≥2 prior systemic therapies
  • Prior therapies must include rituximab and anthracycline (e.g., doxorubicin)
  • Absolute lymphocyte count ≥300/μL within 30 days
  • No active CNS involvement or uncontrolled infection

Common Denial Reasons & How to Fix Them

Denial Reason How to Overturn
"Not medically necessary" Submit comprehensive medical necessity letter with CD19+ confirmation, prior therapy failures, and NCCN guideline citations
"Experimental/investigational" Provide FDA approval letter and prescribing information showing approved indications
"Not at certified center" Transfer care to Illinois certified facility or request network exception if geographically necessary
"Missing prior authorization" Submit complete PA packet with all required clinical documentation
"Insufficient prior therapies" Document specific therapy failures with dates, dosages, and reasons for discontinuation

Internal Appeals Process

Cigna provides two levels of internal appeal before external review becomes available:

Timeline and Submission

  • Filing deadline: 180 calendar days from denial notice
  • Decision timeline: 30 days for medical necessity determinations
  • Expedited timeline: 72 hours for urgent cases

How to File

  1. Call immediately for peer-to-peer review using number on denial letter
  2. Submit written appeal via:

Required Documents

  • Original denial notice or EOB
  • Medical necessity letter from prescribing physician
  • Supporting clinical records (labs, imaging, pathology reports)
  • Documentation of prior therapy failures
  • Current treatment plan including conditioning therapy

Peer-to-Peer Review Strategy

Request a peer-to-peer review immediately upon denial—this often resolves cases fastest without formal appeals.

Preparation Checklist

  • Patient diagnosis and staging information
  • CD19 expression results
  • Complete prior therapy history with specific agents, dates, and outcomes
  • Current disease status and imaging
  • NCCN or other guideline recommendations
  • Conditioning therapy plan (e.g., fludarabine/cyclophosphamide)

Key Talking Points

  • Emphasize FDA approval for patient's specific indication
  • Reference failed standard therapies and contraindications to alternatives
  • Highlight time-sensitive nature of CAR-T therapy
  • Mention certified center's expertise and safety protocols

Illinois External Review Process

If Cigna denies your internal appeals, Illinois law provides independent external review through the Illinois Department of Insurance.

Eligibility and Timeline

  • Filing deadline: 4 months from Cigna's final adverse determination
  • Review timeline: Typically 45 days total; 5 business days for expedited
  • Cost: Free to consumers (insurers pay IRO fees)

How to Request

  1. Obtain external review form from Cigna or IDOI website
  2. Submit with denial letters, medical records, and physician certification
  3. IDOI assigns Independent Review Organization (IRO) with CAR-T expertise
  4. IRO decision is binding on Cigna

Expedited Review

Available if standard review would jeopardize life or health. Requires physician certification of urgency. Decision within 5 business days.

Illinois-specific advantage: The state's external review law requires IROs with specific clinical expertise in your condition, improving reversal rates for complex therapies like CAR-T.

Medical Necessity Letter Template

Your physician's letter should address these key elements:

Patient Information

  • Full name, date of birth, Cigna member ID
  • Primary diagnosis with ICD-10 codes
  • CD19 expression status (include lab report)
  • Current disease stage and performance status

Clinical Rationale

  • Detailed history of prior therapies with specific agents, dates, doses, and outcomes
  • Documentation of refractory disease or relapse
  • Contraindications to standard therapies or alternative CAR-T products
  • Expected clinical benefit based on published literature

Treatment Plan

  • Proposed conditioning regimen
  • Infusion timeline and monitoring plan
  • Post-treatment follow-up schedule
  • Safety monitoring protocols

Supporting Evidence

  • FDA prescribing information citations
  • NCCN guideline recommendations (Category 1 or 2A)
  • Relevant peer-reviewed studies
  • Institutional treatment protocols

Counterforce Health specializes in creating evidence-backed medical necessity letters that align with payer-specific requirements, helping clinicians save time while improving approval rates for complex therapies like CAR-T.

Cost Assistance Options

Even with insurance coverage, CAR-T therapy involves significant out-of-pocket costs:

Manufacturer Support

  • Novartis Oncology Patient Assistance Program: Income-based free drug program
  • Kymriah Co-pay Program: Up to $25,000 annual assistance for eligible commercial patients
  • Contact: 1-844-4KYMRIAH (1-844-459-6742)

Foundation Grants

  • Leukemia & Lymphoma Society: Patient aid program for treatment costs
  • CancerCare: Financial assistance and co-payment help
  • National Foundation for Cancer Research: Emergency financial assistance

State Resources

  • Illinois Medicaid: Expanded coverage includes CAR-T for eligible patients
  • CHIP: Coverage for children up to age 19 in qualifying families

When to Escalate

Illinois Department of Insurance

If experiencing delays or procedural violations:

  • Consumer Helpline: 877-527-9431
  • External Review Unit: 1-877-850-4740
  • File complaint: Online portal for coverage disputes

Illinois Attorney General

  • Health Care Helpline: 1-877-305-5145
  • Can intervene informally with insurers
  • Handles pattern complaints about denial practices
From our advocates: "We've seen Cigna reverse CAR-T denials most often when the appeal includes specific documentation of CD19 positivity and detailed prior therapy failures with dates and outcomes. The key is matching your clinical story to their exact coverage criteria—generic letters rarely succeed."

For complex appeals requiring extensive clinical evidence compilation, services like Counterforce Health can help organize payer-specific documentation that addresses common denial reasons while meeting procedural requirements.

Frequently Asked Questions

Q: How long does Cigna prior authorization take for Kymriah? A: Standard PA decisions take up to 15 business days. Expedited requests (for urgent cases) must be decided within 72 hours. Most CAR-T centers submit 4-6 weeks before planned treatment.

Q: What if Kymriah is non-formulary on my plan? A: Request a formulary exception with medical necessity documentation. Cigna must provide coverage if no formulary alternatives are clinically appropriate for your specific indication.

Q: Can I appeal if I'm denied due to not being at a certified center? A: Yes. If the nearest certified center is geographically inaccessible, request a network adequacy exception. Illinois law requires reasonable access to covered services.

Q: Does step therapy apply if I've tried therapies outside Illinois? A: Yes. Document all prior therapies regardless of where received. Include discharge summaries, pharmacy records, and physician attestations of failure or intolerance.

Q: What happens if I miss the 180-day appeal deadline? A: You lose the right to internal appeal and external review. However, you can still request coverage for future treatment cycles or file a complaint with Illinois DOI about procedural violations.

Q: Are there different rules for Medicare Advantage Cigna plans? A: Yes. Medicare Advantage has shorter deadlines (60 days for appeals) and different external review processes through Medicare rather than Illinois DOI.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage varies by plan and individual circumstances. Always consult your healthcare team and insurance representative for personalized guidance. For assistance with complex appeals, contact the Illinois Department of Insurance at 877-527-9431.

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