By Counterforce Health Team in Oxervate (cenegermin) —

How to Get Oxervate (Cenegermin) Covered by Cigna in Georgia: Complete Prior Authorization and Appeals Guide

Quick Answer: Getting Oxervate (Cenegermin) Covered by Cigna in Georgia

Oxervate (cenegermin) requires prior authorization from Cigna for neurotrophic keratitis treatment. Your ophthalmologist must document stage 2 or 3 neurotrophic keratitis, failed conservative therapies (including 14+ days of preservative-free artificial tears), and submit clinical notes with ICD-10 code H16.22. Coverage is limited to 8 weeks per affected eye initially, with possible extension to 16 weeks total. If denied, you have 180 days to appeal internally, then 60 days for external review through Georgia's Department of Insurance. Start today: Verify your Cigna plan covers specialty ophthalmology drugs and request the current PA form from your provider.

Table of Contents

  1. What This Guide Covers
  2. Before You Start: Plan Verification
  3. Gather Required Documentation
  4. Submit Your Prior Authorization Request
  5. Follow-Up and Tracking
  6. Typical Timelines in Georgia
  7. If Asked for More Information
  8. If Your Request is Denied
  9. Appeals Process in Georgia
  10. Renewal and Re-authorization
  11. Quick Reference Checklist
  12. Frequently Asked Questions

What This Guide Covers

This guide helps patients with neurotrophic keratitis and their eye care providers navigate Cigna's prior authorization process for Oxervate (cenegermin) in Georgia. Whether you're facing your first denial or preparing an appeal, you'll find step-by-step instructions, required forms, and specific timelines that apply in Georgia.

Oxervate is the only FDA-approved treatment for neurotrophic keratitis, a rare corneal disease that can lead to vision loss without proper intervention. While the medication costs in the low six figures for an 8-week course, most patients can get coverage with proper documentation and persistence through the appeals process.

From our advocates: We've seen many Oxervate approvals come through on appeal rather than initial submission. The key is thorough documentation of failed conservative treatments and clear staging of the neurotrophic keratitis. Don't give up after the first denial—Georgia's external review process has helped many patients access this sight-saving medication.

Before You Start: Plan Verification

Confirm Your Coverage Type

First, determine which type of Cigna plan you have:

  • Commercial/employer plans: Managed through Express Scripts for specialty drugs
  • Medicare Advantage: May have different formulary requirements
  • Medicaid: Different approval pathway entirely

Call the member services number on your insurance card to confirm your plan type and verify that specialty ophthalmology medications are covered.

Check Formulary Status

Oxervate's formulary status with Cigna varies by plan. It may be:

  • Covered with prior authorization (most common)
  • Non-formulary (requiring formulary exception)
  • Subject to step therapy (try other treatments first)

You can check your plan's formulary at Cigna's website or by calling member services.

Gather Required Documentation

Medical Records You'll Need

Your ophthalmologist must provide:

Diagnosis Documentation:

  • Confirmation of neurotrophic keratitis stage 2 or 3
  • ICD-10 code H16.22 (Keratitis interstitial, neurotrophic)
  • Corneal sensitivity testing results
  • Slit lamp examination findings with measurements
  • Fluorescein staining photos or descriptions

Prior Treatment History:

  • Documentation of at least 14 days of preservative-free artificial tears
  • Trial and failure of therapeutic contact lenses (if applicable)
  • Any other conservative treatments attempted (bandage contact lens, tarsorrhaphy, amniotic membrane)
  • Reasons why each treatment failed or was inappropriate

Clinical Justification:

  • Why Oxervate is medically necessary
  • Risk of progression without treatment
  • Treatment goals and expected outcomes

Insurance Information

Gather these documents:

  • Current insurance card
  • Recent Explanation of Benefits (EOB)
  • Any prior denial letters
  • Previous prior authorization attempts

Submit Your Prior Authorization Request

Step 1: Get the Current PA Form

Your provider needs to obtain Cigna's current prior authorization form for Oxervate. Forms change periodically, so always use the most recent version available through:

  • Cigna provider portal (confirm current link with your doctor's office)
  • Express Scripts provider resources
  • Direct contact with Cigna's prior authorization department

Step 2: Complete Medical Necessity Criteria

According to Cigna's policy, your request must demonstrate:

Requirement Documentation Needed
Diagnosis Stage 2 or 3 neurotrophic keratitis
Prescriber Ophthalmologist or optometrist
Prior therapies Failed preservative-free artificial tears (≥14 days)
Duration limit Maximum 8 weeks per eye initially
Age requirement Patient must be 2 years or older

Step 3: Submit Through Proper Channels

Most Cigna specialty drug requests go through Express Scripts. Your provider should:

  • Submit via the Express Scripts provider portal
  • Include all supporting documentation
  • Request expedited review if medically urgent
  • Keep copies of all submitted materials
Tip: Ask your provider to request a "peer-to-peer review" upfront if the case is complex. This allows your ophthalmologist to speak directly with Cigna's medical director.

Follow-Up and Tracking

When to Call

  • 3-5 business days after submission: Confirm receipt
  • 10-14 days after submission: Check status if no response
  • Before the deadline: If additional information is requested

What to Ask

When calling Cigna (member services number on your card):

  • "What's the status of my Oxervate prior authorization?"
  • "What's the reference number for tracking?"
  • "When should I expect a decision?"
  • "Is any additional information needed?"

Sample Call Script

"Hi, I'm calling to check on a prior authorization request for Oxervate for neurotrophic keratitis. My member ID is [number], and the request was submitted on [date]. Can you tell me the current status and reference number?"

Typical Timelines in Georgia

Standard Review

  • Cigna decision: Within 72 hours for standard requests
  • Expedited review: Within 24 hours if urgent
  • Express Scripts: May take up to 72 hours for specialty drugs

Appeals Timeline

  • Internal appeal filing deadline: 180 days from denial
  • Internal appeal decision: 30 calendar days (72 hours if expedited)
  • External review filing deadline: 60 days from final internal denial
  • External review decision: 30 business days (72 hours if expedited)

If Asked for More Information

Common Requests

Cigna may ask for:

  • More detailed prior treatment documentation
  • Specialist consultation notes
  • Corneal photography or imaging
  • Treatment response documentation

How to Respond

  • Provide requested information promptly
  • Include a cover letter summarizing why Oxervate is necessary
  • Reference specific medical literature supporting the treatment
  • Ask for expedited processing if the delay poses health risks

If Your Request is Denied

Common Denial Reasons and Solutions

Denial Reason How to Address
Insufficient prior therapy Document all conservative treatments tried and failed
Lack of staging documentation Provide detailed corneal examination with staging
Not medically necessary Include specialist letter explaining disease progression risk
Formulary restriction Request formulary exception with clinical justification

Preparing Your Appeal

When appealing a Cigna denial:

  1. Request the complete denial letter with specific reasons
  2. Gather additional evidence addressing each denial point
  3. Get a detailed letter from your ophthalmologist explaining medical necessity
  4. Include peer-reviewed literature supporting Oxervate use
  5. Submit within 180 days of the denial date

Appeals Process in Georgia

Internal Appeals (Cigna)

First-Level Appeal:

  • File within 180 days of denial
  • Submit written appeal with new clinical evidence
  • Decision within 30 days (72 hours if expedited)
  • Can request peer-to-peer review

Second-Level Appeal:

  • Available if first level is denied
  • Similar timeline and process
  • Final internal decision from Cigna

External Review (Georgia Department of Insurance)

If Cigna denies your internal appeals, you can request external review through Georgia's Department of Insurance:

Eligibility:

  • Must complete Cigna's internal appeal process first
  • Denial must be based on medical necessity or experimental/investigational determination
  • Must file within 60 days of final internal denial

Process:

  • Submit application to Georgia DOI Consumer Services
  • No cost to you
  • Independent medical reviewers evaluate your case
  • Decision is binding on Cigna

Contact Information: Georgia Office of Commissioner of Insurance and Fire Safety Consumer Services: 1-800-656-2298

Renewal and Re-authorization

When Coverage Ends

Cigna typically approves Oxervate for:

  • Initial treatment: 8 weeks per affected eye
  • Possible extension: Up to 16 weeks total per eye for recurrence
  • Lifetime limit: Most plans limit to one course per eye

Re-treatment Requests

If neurotrophic keratitis recurs after successful treatment:

  • Document the recurrence with new clinical findings
  • Show that the initial course was successful
  • Provide clinical rationale for re-treatment
  • Submit new prior authorization request with updated documentation

Quick Reference Checklist

Before Starting:

  • Verify Cigna plan type and formulary status
  • Confirm ophthalmologist is in-network
  • Check if Express Scripts manages your specialty drugs

Documentation Needed:

  • Stage 2 or 3 neurotrophic keratitis diagnosis (ICD-10: H16.22)
  • Failed conservative therapy documentation (≥14 days artificial tears)
  • Corneal examination findings with measurements
  • Specialist treatment recommendation letter

Submission Process:

  • Complete current Cigna PA form
  • Submit through Express Scripts (if applicable)
  • Request expedited review if urgent
  • Keep copies of all documents

If Denied:

  • Request complete denial letter
  • File internal appeal within 180 days
  • Consider peer-to-peer review
  • File external review within 60 days if needed

Frequently Asked Questions

How long does Cigna take to approve Oxervate in Georgia? Standard prior authorization decisions are made within 72 hours. Expedited reviews (for urgent cases) are decided within 24 hours.

What if Oxervate is not on my Cigna formulary? You can request a formulary exception by providing clinical documentation showing medical necessity and why formulary alternatives are inappropriate.

Can I request an expedited appeal in Georgia? Yes, both Cigna internal appeals and Georgia external reviews can be expedited if your condition poses immediate health risks. Expedited decisions are made within 72 hours.

Does step therapy apply to Oxervate? Most Cigna plans require documentation of failed conservative therapies (artificial tears, therapeutic contact lenses) before approving Oxervate, but specific step therapy requirements vary by plan.

What if I can't afford Oxervate while waiting for approval? Contact Dompé Farmaceutici's patient assistance program or ask your provider about manufacturer samples while your authorization is pending.

How often can I get Oxervate covered? Most Cigna plans limit coverage to 8 weeks initially, with possible extension to 16 weeks total per affected eye. Re-treatment for recurrence may be possible with additional documentation.

What happens if Georgia external review denies my appeal? External review decisions are final for the administrative process. Further options would require legal consultation, though this is rare.

Can my regular eye doctor prescribe Oxervate? Cigna requires prescription by an ophthalmologist or optometrist. Some plans may require subspecialty training in corneal diseases.

For complex cases involving rare diseases like neurotrophic keratitis, having expert support can make the difference between approval and denial. Counterforce Health specializes in helping patients and providers navigate insurance denials by creating targeted, evidence-backed appeals that address payer-specific requirements and turn denials into approvals.

Sources & Further Reading

Disclaimer: This guide provides general information about insurance coverage processes and should not be considered medical or legal advice. Insurance policies and state regulations change frequently. Always verify current requirements with your insurance company and consult with your healthcare provider about treatment decisions. For personalized assistance with your specific situation, contact your insurance company directly or consult with a qualified healthcare advocate.

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