By Counterforce Health Team in Mycapssa (octreotide, oral) —

How to Get Mycapssa (Octreotide) Covered by Cigna in California: ICD-10 Codes, Prior Authorization, and Appeal Success Strategies

Answer Box: Getting Mycapssa Covered by Cigna in California

Mycapssa (oral octreotide) requires prior authorization from Cigna with ICD-10 code E22.0 (acromegaly) and documented response to injectable octreotide or lanreotide. Submit through Accredo Specialty Pharmacy with complete clinical documentation. If denied, California residents can file an Independent Medical Review (IMR) through DMHC with 50-65% success rates for rare disease appeals.

First steps: Gather injectable SSA response records, current IGF-1/GH labs, and have your endocrinologist submit the PA request through Cigna's provider portal within 180 days of the prescription.

Table of Contents

  1. Coding Basics: Medical vs. Pharmacy Benefit
  2. ICD-10 Mapping and Documentation
  3. Product Coding: NDC, Units, and Billing
  4. Clean Prior Authorization Request
  5. Common Coding Pitfalls
  6. Verification with Cigna Resources
  7. California Appeals Process
  8. Pre-Submission Audit Checklist

Coverage at a Glance

Requirement Details Where to Find Source
Prior Authorization Required for all Cigna plans Cigna provider portal Cigna PA Policy
Formulary Status Specialty tier, non-preferred Cigna formulary Cigna Drug Lists
Specialty Pharmacy Accredo required Member ID card Accredo Info
ICD-10 Code E22.0 (acromegaly) Clinical documentation FDA Label
Appeal Deadline 180 days (internal), 6 months (IMR) Denial letter DMHC Guidelines

Coding Basics: Medical vs. Pharmacy Benefit

Mycapssa follows the pharmacy benefit pathway since it's an oral medication dispensed by specialty pharmacy. Unlike injectable octreotide (which may bill under medical benefit with J-codes), Mycapssa uses NDC numbers for pharmacy claims processing.

Key Distinction:

  • Medical Benefit: Injectable SSAs (Sandostatin LAR, Somatuline Depot) with HCPCS J-codes
  • Pharmacy Benefit: Mycapssa with NDC codes through Accredo

This difference affects where you submit prior authorization requests and how claims are processed through Cigna's system.

ICD-10 Mapping and Documentation

Primary Diagnosis Code

E22.0 - Acromegaly and pituitary gigantism is the primary ICD-10 code for Mycapssa coverage. This must be supported by clinical documentation including:

  • Elevated IGF-1 levels above age-adjusted normal ranges
  • Failure of growth hormone suppression during oral glucose tolerance testing
  • MRI evidence of pituitary adenoma (when present, add D35.2)
  • Clinical signs and symptoms consistent with acromegaly

Documentation Requirements for Medical Necessity

Your clinical notes must explicitly demonstrate:

  1. Confirmed acromegaly diagnosis with biochemical evidence
  2. Prior response to injectable somatostatin analogs (octreotide or lanreotide)
  3. Medical rationale for oral therapy (injection site reactions, patient preference with clinical justification, or access issues)
  4. Current disease monitoring with IGF-1/GH levels and imaging
Clinician Tip: Document specific IGF-1 values before and during injectable therapy to demonstrate response. Include exact dates of treatment periods and reasons for considering oral conversion.

Product Coding: NDC, Units, and Billing

NDC Numbers for Mycapssa

  • Primary NDCs: 69880-120-28 and 10122-550-28
  • Package Size: 28 capsules (4 blister packs of 7 capsules each)
  • Strength: 20 mg per capsule

Units Conversion and Billing

Daily Dose to Capsule Conversion:

  • 40 mg/day = 2 capsules daily (56 capsules per 28 days)
  • 60 mg/day = 3 capsules daily (84 capsules per 28 days)
  • 80 mg/day = 4 capsules daily (112 capsules per 28 days)

Critical: Always prescribe by number of capsules, not total milligrams. Write "Mycapssa 20 mg capsules, take 2 capsules twice daily" rather than "Mycapssa 80 mg daily."

Quantity Limits

Cigna typically approves 28-day supplies with quantity limits matching the prescribed daily dose. Requests for larger quantities require additional justification for medical necessity.

Clean Prior Authorization Request

Required Documentation Checklist

Clinical Information:

  • Current specialist (endocrinologist) evaluation within 90 days
  • Acromegaly diagnosis with ICD-10 code E22.0
  • Recent IGF-1 and growth hormone levels
  • Pituitary imaging (MRI) results

Prior Therapy Documentation:

  • Injectable SSA treatment history (octreotide or lanreotide)
  • Duration of injectable therapy and dosing
  • Evidence of biochemical response (IGF-1/GH suppression)
  • Documented reasons for switching to oral therapy

Prescription Details:

  • Exact capsule strength and quantity
  • NDC number for billing
  • 28-day supply specification
  • Prescriber DEA and NPI numbers
From our advocates: We've seen the fastest approvals when endocrinologists include a one-page summary showing before-and-after IGF-1 levels from injectable therapy, along with a clear statement about why oral therapy is now medically appropriate. This gives reviewers exactly what they need without sifting through lengthy records.

Common Coding Pitfalls

Unit Conversion Errors

  • Wrong: Prescribing "80 mg daily" (unclear to pharmacy)
  • Right: "Take 2 capsules twice daily (total 4 capsules daily)"

Missing Documentation

  • Wrong: Generic "patient requests oral therapy"
  • Right: "Patient experienced injection site nodules with Sandostatin LAR, documented in notes from [date]"

Incorrect Billing Path

  • Wrong: Submitting to medical benefit with J-code
  • Right: Pharmacy benefit through Accredo with NDC

Timing Issues

  • Wrong: Submitting PA after 30-day prescription expires
  • Right: Submit PA immediately upon prescription to allow processing time

Verification with Cigna Resources

Before Submission

  1. Confirm current formulary status at Cigna Drug Lists
  2. Verify specialty pharmacy requirement (Accredo for most plans)
  3. Check PA form version - use current year forms only
  4. Confirm member eligibility and active coverage

During Processing

  • Track submission with reference numbers
  • Follow up weekly on pending requests
  • Respond promptly to requests for additional information
  • Document all communications with Cigna representatives

California Appeals Process

Internal Appeal with Cigna

Timeline: File within 180 days of denial Process: Submit through member portal or mail with supporting documentation Decision: Cigna responds within 60 days (expedited reviews in 24-72 hours)

Independent Medical Review (IMR)

If Cigna upholds the denial, California residents can request an IMR through the Department of Managed Health Care (DMHC).

Key Advantages:

  • Success rates: 50-65% for specialty/rare disease drugs
  • Independent review by specialty experts
  • Binding decision - Cigna must comply if overturned
  • No cost to patient

Timeline:

  • File within 6 months of final internal denial
  • DMHC decision within 45 days (7 days for urgent cases)

How to File: Visit healthhelp.ca.gov or call DMHC Help Center at 888-466-2219

Required IMR Documentation

  • Complete denial correspondence from Cigna
  • All medical records supporting medical necessity
  • Specialist letter explaining clinical rationale
  • Published clinical guidelines or studies supporting use
  • Evidence of prior injectable SSA response

Counterforce Health: Streamlining Your Appeals

When facing complex prior authorization requirements or denials, Counterforce Health helps patients and clinicians turn insurance denials into targeted, evidence-backed appeals. The platform analyzes denial letters and plan policies to draft point-by-point rebuttals aligned with Cigna's specific requirements, pulling appropriate citations from FDA labeling, peer-reviewed studies, and specialty guidelines to support Mycapssa coverage requests.

Pre-Submission Audit Checklist

Clinical Documentation ✓

  • Acromegaly diagnosis confirmed with E22.0 code
  • Current IGF-1 and GH levels documented
  • Prior injectable SSA response clearly documented
  • Medical necessity for oral therapy explained
  • Endocrinologist evaluation within 90 days

Prescription Accuracy ✓

  • Capsule strength and quantity specified correctly
  • NDC number included for billing
  • 28-day supply indicated
  • Prescriber information complete

Submission Requirements ✓

  • Current PA form used
  • All required attachments included
  • Member information verified
  • Accredo specialty pharmacy confirmed
  • Submission tracking number obtained

Follow-Up Plan ✓

  • Calendar reminders for status checks
  • Appeal deadline noted (180 days)
  • IMR option documented for California
  • Contact information for DMHC saved

Frequently Asked Questions

How long does Cigna prior authorization take for Mycapssa? Standard reviews take up to 60 days. Expedited reviews (for urgent medical situations) are completed within 24-72 hours.

What if Mycapssa isn't on Cigna's formulary? You can request a formulary exception with clinical justification. Your doctor must demonstrate medical necessity and why preferred alternatives aren't appropriate.

Can I appeal if I live in California but have coverage through an employer in another state? Yes, California residents can use the state's IMR process regardless of where their employer or plan is based, as long as they receive care in California.

Does step therapy apply to Mycapssa? Most Cigna plans require documented trial and response to injectable somatostatin analogs before approving oral octreotide.

What's the cost without insurance approval? Approximately $6,685 for a 28-day supply (56 capsules). Counterforce Health can help navigate coverage options and appeals to avoid these out-of-pocket costs.

How do I request an expedited review? Contact Cigna directly if your medical condition could be seriously jeopardized by delays. Provide documentation from your physician supporting the urgent need.

Sources & Further Reading

Disclaimer: This information is for educational purposes and does not constitute medical or legal advice. Coverage decisions depend on individual plan terms and medical circumstances. Always consult with your healthcare provider and insurance plan for specific guidance. For assistance with complex appeals, consider consulting with organizations like Counterforce Health that specialize in insurance coverage advocacy.

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