By Counterforce Health Team in Photrexa (riboflavin ophthalmic solution) —

How to Get Photrexa (Riboflavin) Covered by Cigna in Virginia: Complete Prior Authorization and Appeals Guide

Answer Box: Getting Photrexa Covered by Cigna in Virginia

Cigna requires prior authorization for Photrexa (riboflavin ophthalmic solution) used in corneal cross-linking for keratoconus in Virginia. Your ophthalmologist must document progressive disease with serial corneal topography showing ≥1.0 diopter increase in maximum keratometry (Kmax) and failed conservative treatments. Submit the PA through Cigna's provider portal with progression evidence, prior therapy documentation, and clinical notes. Standard review takes 3-5 business days. If denied, file an internal appeal within 180 days, followed by Virginia's external review process through the State Corporation Commission if needed.

First step today: Contact your eye doctor to ensure they have documented disease progression and can submit the prior authorization with complete supporting evidence.

Table of Contents

  1. Patient Profile: Understanding Photrexa Coverage
  2. Pre-Authorization Preparation
  3. Submission Process
  4. Initial Outcome: Approval or Denial
  5. Appeals Process in Virginia
  6. Resolution and Coverage Terms
  7. Key Takeaways
  8. Coverage Requirements at a Glance
  9. Common Denial Reasons & Solutions
  10. Virginia External Review Process
  11. FAQ

Patient Profile: Understanding Photrexa Coverage

Photrexa (riboflavin ophthalmic solution) is used with the iLink® system for epithelium-off corneal collagen cross-linking in patients with progressive keratoconus or corneal ectasia. The procedure typically costs $2,500-$4,000 per eye, making insurance coverage crucial for most patients.

Typical Patient Scenario: Sarah, a 24-year-old Virginia resident with Cigna coverage, has been experiencing worsening vision despite contact lens adjustments. Her ophthalmologist diagnosed progressive keratoconus and recommended corneal cross-linking with Photrexa to halt disease progression and preserve her remaining vision.

The key to approval lies in documenting that your keratoconus is actively progressing and that less intensive treatments have failed or are inadequate.

Pre-Authorization Preparation

Essential Documentation Requirements

Your ophthalmologist must gather specific clinical evidence to support the prior authorization request:

1. Progression Documentation

  • Serial corneal topography showing quantitative changes over time
  • Increase in maximum keratometry (Kmax) of ≥1.0 diopter from baseline
  • Decrease in central corneal thickness (pachymetry) of >2% from baseline
  • Dated clinical notes confirming progressive keratoconus diagnosis (ICD-10: H18.621)

2. Prior Treatment History

  • Documentation of failed or inadequate contact lens correction
  • Records showing insufficient vision correction with glasses
  • Clinical notes explaining why conservative management is no longer sufficient

3. Medical Necessity Statement

  • Clear explanation of treatment goals (halt progression, preserve vision)
  • Justification for FDA-approved epithelium-off protocol with Photrexa
  • Statement of risks if treatment is delayed
Clinician Corner: Your medical necessity letter should emphasize that only the epithelium-off corneal cross-linking protocol using Photrexa is FDA-approved for progressive keratoconus. Reference the FDA approval and include specific topographic measurements showing disease progression.

Submission Process

Step-by-Step Submission Guide

1. Provider Portal Access (Ophthalmologist's office)

  • Log into Cigna's provider portal or use CoverMyMeds
  • Navigate to prior authorization section
  • Select "Photrexa (riboflavin ophthalmic solution)"

2. Required Forms and Documentation

  • Complete Cigna's specialty drug prior authorization form
  • Attach progression documentation (topography reports, pachymetry)
  • Include medical necessity letter with clinical rationale
  • Submit prior treatment records

3. Processing Timeline

  • Standard review: 3-5 business days
  • Expedited review: 24-72 hours (for urgent cases)
  • Track status through myCigna portal or provider dashboard

4. Notification Process

  • Both patient and provider receive determination via portal and mail
  • Approval includes coverage details and any requirements
  • Denials include specific reasons and appeal instructions

Initial Outcome: Approval or Denial

If Approved

Your approval letter will specify:

  • Coverage effective dates
  • Any quantity limitations
  • Required facility or provider network restrictions
  • Patient cost-sharing responsibilities

If Denied

Common denial reasons include:

  • Insufficient progression documentation
  • Missing prior treatment failure records
  • Use of non-FDA approved protocol
  • Incomplete clinical justification

Don't lose hope—many initial denials are overturned on appeal when additional evidence is provided.

Appeals Process in Virginia

Internal Appeal with Cigna

Timeline: File within 180 days of denial notice

Required Steps:

  1. Submit written appeal through Cigna provider portal or mail
  2. Include additional clinical documentation addressing denial reasons
  3. Request peer-to-peer review if available
  4. Await determination within 72 hours (standard) or 24 hours (expedited)

Supporting Evidence for Appeals:

  • Additional topographic measurements
  • Peer-reviewed literature supporting treatment necessity
  • Specialist consultation notes
  • Updated visual acuity measurements

Peer-to-Peer Review

If your ophthalmologist requests it, Cigna may arrange a peer-to-peer discussion between your doctor and their medical reviewer. This allows direct clinical dialogue about your case and can be highly effective for complex situations.

Virginia External Review Process

If Cigna's internal appeal is denied, Virginia residents have access to an independent external review through the State Corporation Commission (SCC).

External Review Requirements

  • Must complete Cigna's internal appeals process first
  • File within 120 days of final internal denial
  • Submit Form 216-A to SCC Bureau of Insurance
  • Include all denial letters and supporting clinical documentation

Timeline and Process

  • Standard Review: Decision within 45 days
  • Expedited Review: Decision within 72 hours for urgent cases
  • Binding Decision: Insurers must comply with external review determinations

Contact Information: Virginia State Corporation Commission Bureau of Insurance External Review Unit Phone: 1-877-310-6560

From Our Advocates: We've seen several Virginia patients successfully overturn Photrexa denials through external review by providing comprehensive progression documentation that wasn't initially submitted. The key is ensuring the independent reviewer has complete clinical context about why cross-linking is necessary now versus waiting.

Resolution and Coverage Terms

Successful Coverage Outcomes

Once approved, patients typically receive:

  • Coverage for the complete procedure (drug + device + facility)
  • Network provider requirements specified
  • Clear cost-sharing information
  • Authorization valid for specific time period

What to Expect

  • Procedure scheduling with approved facility
  • Pre-treatment requirements (discontinue contact lenses)
  • Post-procedure follow-up coverage
  • Potential coverage for second eye if bilateral disease

Key Takeaways

Most Important Success Factors:

  1. Document progression objectively with serial topography and quantitative measurements
  2. Emphasize FDA approval of epithelium-off protocol with Photrexa
  3. Show failed conservative therapy with specific examples and dates
  4. Submit complete documentation initially to avoid delays
  5. Appeal promptly if denied, with additional supporting evidence

What We'd Do Differently:

  • Ensure baseline topography is properly dated and documented
  • Include posterior elevation maps, which are more sensitive for progression
  • Prepare peer-reviewed citations supporting cross-linking efficacy
  • Coordinate with specialty pharmacy early in the process

Coverage Requirements at a Glance

Requirement Details Documentation Needed
Prior Authorization Required for all Photrexa requests PA form via provider portal
Progression Evidence Kmax increase ≥1.0D, pachymetry decrease >2% Serial corneal topography
Prior Treatments Failed contact lens or inadequate correction Clinical notes, prescription history
FDA Protocol Epithelium-off with iLink® system only Procedure details in request
Diagnosis Code Progressive keratoconus (H18.621) ICD-10 documentation
Appeal Deadline 180 days from denial Written appeal with new evidence
External Review 120 days from final internal denial Form 216-A to Virginia SCC

Common Denial Reasons & Solutions

Denial Reason Solution Strategy
Insufficient progression documentation Submit additional topography with clear Kmax/pachymetry changes over time
Missing prior treatment failures Provide detailed contact lens trial records and fitting notes
Non-FDA approved protocol requested Confirm epithelium-off procedure with Photrexa and iLink® system
Incomplete medical necessity Enhanced clinical letter emphasizing vision preservation goals
Out-of-network facility Identify Cigna-contracted surgical centers or request exception

FAQ

How long does Cigna prior authorization take for Photrexa in Virginia? Standard review takes 3-5 business days. Expedited review for urgent cases is completed within 24-72 hours.

What if Photrexa is non-formulary on my Cigna plan? You can request a formulary exception through Cigna's standard process, providing medical necessity documentation and evidence that covered alternatives are inappropriate.

Can I request expedited review for keratoconus? Yes, if your ophthalmologist documents that delayed treatment could result in significant vision loss or rapid disease progression.

Does Virginia require step therapy for corneal cross-linking? Most Cigna policies require documentation of failed conservative management (contact lenses, glasses) before approving cross-linking procedures.

What happens if my external review is denied? While external review decisions are binding on insurers, you retain the right to pursue other legal options or seek coverage through alternative programs.

Are there financial assistance programs for Photrexa? Contact Glaukos (the manufacturer) about patient assistance programs, and check with your ophthalmologist about clinical trial opportunities or foundation grants.

Counterforce Health helps patients navigate complex prior authorization and appeal processes for specialty treatments like Photrexa. Our platform analyzes denial letters, identifies specific coverage criteria, and generates evidence-backed appeals tailored to your insurer's requirements. By turning insurance obstacles into targeted advocacy, we help patients access the treatments they need while reducing the administrative burden on healthcare providers.

If you're facing challenges with Photrexa coverage or other specialty drug approvals, Counterforce Health can provide the expertise and documentation support needed to improve your chances of success.

Sources & Further Reading

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 clinical circumstances. Always consult with your healthcare provider and insurance company for specific coverage questions, and consider consulting with qualified professionals for complex appeals or legal matters.

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