By Counterforce Health Team in Nourianz (istradefylline) —

How to Get Nourianz (Istradefylline) Covered by Cigna in North Carolina: Appeals Guide with Forms and Timelines

Answer Box: Getting Nourianz Covered by Cigna in North Carolina

Cigna requires prior authorization for Nourianz (istradefylline) with strict step therapy requirements. You must have tried and failed amantadine, a MAO-B inhibitor (like rasagiline), and a COMT inhibitor (like entacapone) before approval. If denied, Cigna members have strong appeal rights in North Carolina with over 80% success rates.

Fastest path to approval:

  1. Gather documentation of failed trials with required medications
  2. Submit detailed motor diary showing OFF episodes
  3. If denied, request peer-to-peer review immediately
  4. Use North Carolina's Smart NC external review if internal appeals fail

Table of Contents

Understanding Cigna's Requirements

Nourianz (istradefylline) is a once-daily medication that helps reduce "OFF" episodes in Parkinson's disease patients already taking levodopa/carbidopa. At approximately $1,900-$2,100 for a 30-day supply, Cigna manages this specialty drug through Express Scripts with strict prior authorization requirements.

Coverage Requirements at a Glance

Requirement What It Means Where to Find Documentation
Step Therapy Must try amantadine, MAO-B inhibitor, COMT inhibitor first Previous prescription records, clinic notes
Concurrent Levodopa Patient must be taking carbidopa/levodopa Current medication list
OFF Episode Documentation At least 3 hours daily of motor fluctuations Motor diary (2-3 consecutive days)
Neurologist Involvement Specialist evaluation and ongoing care Referrals, specialist notes
Prior Authorization Required before dispensing Cigna provider portal

Reading Your Denial Letter

When Cigna denies Nourianz, you'll receive an Explanation of Benefits (EOB) or denial letter. Look for these key elements:

Critical Information to Extract:

  • Denial reason code (step therapy, medical necessity, non-formulary)
  • Appeal deadline (typically 180 days for internal appeals)
  • Required documentation for reversal
  • Contact information for appeals

Common Cigna Denial Reasons:

  • "Step therapy not met" - haven't tried required alternatives
  • "Insufficient clinical documentation" - missing motor diary or specialist notes
  • "Not medically necessary" - inadequate justification for OFF episodes
  • "Quantity limits exceeded" - requesting more than approved amount

Fixable Causes of Denial

Many Nourianz denials can be overturned by addressing documentation gaps:

Missing Step Therapy Documentation

The Fix: Provide clear evidence of trials with:

  • Amantadine - prescription history showing inadequate response or intolerance
  • MAO-B inhibitor (rasagiline, safinamide) - documented failure or side effects
  • COMT inhibitor (entacapone, opicapone) - insufficient benefit or adverse reactions

Inadequate OFF Episode Documentation

The Fix: Submit a detailed motor diary showing:

  • Hour-by-hour ON/OFF states over 2-3 consecutive days
  • Medication timing and response
  • Functional impact of OFF episodes
  • Total daily OFF time (should be ≥3 hours)

Missing Clinical Justification

The Fix: Include neurologist notes documenting:

  • Parkinson's diagnosis with ICD-10 code G20
  • Current levodopa regimen and optimization attempts
  • UPDRS scores (especially Part IV for motor complications)
  • Treatment goals and expected outcomes

First-Level Appeal Strategy

Counterforce Health helps patients and clinicians turn insurance denials into evidence-backed appeals by identifying the specific denial basis and crafting targeted rebuttals aligned to each plan's own coverage rules. Their platform streamlines the complex appeals process by pulling the right clinical citations and weaving them into compelling medical necessity arguments.

Medical Necessity Letter Checklist

Your appeal should include:

Clinical Problem Statement:

  • Parkinson's diagnosis with motor fluctuations
  • Specific OFF episode duration and impact
  • Functional limitations during OFF periods

Prior Treatment History:

  • Complete list of tried Parkinson's medications
  • Specific reasons for discontinuation (inadequate response, side effects, contraindications)
  • Duration of each trial and outcomes

Evidence-Based Rationale:

  • FDA-approved indication for OFF episodes
  • Clinical guidelines supporting use as adjunct therapy
  • Expected benefits and monitoring plan

Required Documentation Checklist

  • Completed prior authorization form
  • Motor diary (minimum 2-3 consecutive days)
  • Neurologist consultation notes
  • Medication history with trial outcomes
  • UPDRS scores if available
  • Laboratory results (liver function if relevant)
  • Insurance card and member ID

Peer-to-Peer Review Process

Request immediately after denial - this phone consultation between your neurologist and Cigna's medical director often resolves complex cases without formal written appeals.

Preparing for Peer-to-Peer

Neurologist Should Have Ready:

  • Patient's complete Parkinson's history
  • Specific documentation of failed step therapy
  • Motor diary results and functional impact
  • Clinical rationale for Nourianz specifically
  • Treatment goals and monitoring plan

Key Talking Points:

  • Emphasize inadequate control despite optimized levodopa
  • Document specific failures with required step therapy agents
  • Highlight functional impact of OFF episodes on daily activities
  • Reference clinical guidelines supporting adjunct therapy

North Carolina External Review

If Cigna's internal appeals fail, North Carolina offers robust external review rights through Smart NC.

Timeline and Process

Step Timeline Action Required
Internal Appeals Complete first Exhaust Cigna's appeal levels
External Review Request Within 120 days Submit to Smart NC
Standard Review 45 days IRO decision
Expedited Review 3 days For urgent situations

How to Request External Review

  1. Complete Internal Appeals: Must finish Cigna's process first
  2. Submit Request: Download form from NC Department of Insurance
  3. Include Documentation: All denial letters, medical records, appeal correspondence
  4. IRO Assignment: Smart NC assigns Independent Review Organization
  5. Final Decision: Binding on both patient and Cigna

Contact Smart NC: 1-855-408-1212 for free advocacy support

From Our Advocates: We've seen numerous Nourianz appeals succeed when patients document clear functional improvement needs and provide comprehensive step therapy failure records. The key is showing that OFF episodes significantly impact daily activities despite trying all required alternatives. This composite guidance reflects common successful appeal patterns.

Appeal Templates and Scripts

Patient Phone Script for Cigna

"I'm calling to appeal the denial of Nourianz for my Parkinson's disease. My member ID is [ID number]. I have documentation showing I've tried the required step therapy medications without success, and I have a detailed motor diary showing significant OFF episodes. I'd like to request a peer-to-peer review with my neurologist and understand the formal appeal process."

Medical Necessity Letter Template

Subject: Appeal for Nourianz (Istradefylline) - Member [ID]

Patient Overview: [Name] is a [age]-year-old with Parkinson's disease experiencing motor fluctuations despite optimized levodopa therapy.

Clinical Justification: Motor diary demonstrates [X] hours daily of OFF episodes significantly impacting [specific activities]. Patient has inadequate response to required step therapy:

  • Amantadine: [specific outcome/intolerance]
  • [MAO-B inhibitor]: [specific outcome/intolerance]
  • [COMT inhibitor]: [specific outcome/intolerance]

Treatment Plan: Nourianz 20mg daily as adjunct to current levodopa regimen with monthly monitoring for efficacy and side effects.

Tracking Your Appeal

Appeal Log Template

Date Action Taken Contact Method Outcome Next Step Deadline
[Date] Submitted PA Provider portal Denied File appeal [180 days]
[Date] Called for peer-to-peer Phone Scheduled Prepare materials [Date]
[Date] Submitted appeal Fax Pending Follow up [Date]

When to Escalate

File complaint with North Carolina if:

  • Appeals exceed published timelines
  • Cigna fails to respond to requests
  • Procedural violations occur
  • Pattern of inappropriate denials

Contact: NC Department of Insurance Consumer Services at 1-855-408-1212

When Appeals Fail: Alternatives

Manufacturer Support Programs

  • Nourianz Savings Program: May reduce copays for eligible patients
  • Patient Assistance Programs: Income-based free medication
  • Foundation Grants: Organizations supporting Parkinson's patients

Alternative Medications

If Nourianz remains denied, discuss these adjunct options:

  • Safinamide (Xadago): MAO-B inhibitor for OFF episodes
  • Opicapone (Ongentys): COMT inhibitor alternative
  • Apomorphine (Apokyn): Injectable rescue therapy

Formulary Exception Requests

Even if non-formulary, Cigna may cover Nourianz through medical exception process with strong clinical justification.

FAQ

How long does Cigna prior authorization take in North Carolina? Standard PA decisions: 72 hours. Expedited requests: 24 hours. Appeals: up to 30 days for internal review.

What if I've tried step therapy medications outside North Carolina? Documentation from any licensed provider is acceptable. Ensure records clearly show medication names, doses, duration, and outcomes.

Can I request expedited appeal for Nourianz? Yes, if delay would seriously jeopardize health or recovery. Requires physician certification of urgency.

Does Cigna cover Nourianz for all Parkinson's patients? No, only for those with documented OFF episodes despite optimized levodopa therapy who've failed required step therapy.

What happens if Smart NC external review denies coverage? The IRO decision is final and binding. Consider alternative medications or manufacturer assistance programs.

How much does Nourianz cost without insurance? Approximately $1,900-$2,100 for 30 tablets. Manufacturer copay programs may reduce costs for eligible patients.

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage decisions depend on individual policy terms and medical circumstances. Always consult with your healthcare provider and insurance company for personalized guidance.

For additional support with insurance appeals and prior authorization challenges, Counterforce Health provides specialized assistance in turning denials into successful approvals through evidence-based appeal strategies.

Sources & Further Reading

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