By Counterforce Health Team in Stelara (ustekinumab) —

How to Get Stelara (Ustekinumab) Covered by Cigna in New Jersey: Coding, Appeals, and Step Therapy Guide

Quick Answer: To get Stelara (ustekinumab) covered by Cigna in New Jersey, you'll need prior authorization with specific ICD-10 codes, documented step therapy failures, and TB screening. If denied, New Jersey's IHCAP external review program (managed by Maximus Federal Services) overturns about 68% of specialty drug denials. Start by gathering your diagnosis documentation and prior treatment history today.

Table of Contents

  1. Coverage Requirements Overview
  2. ICD-10 Coding and Documentation
  3. HCPCS J-Codes and NDC Numbers
  4. Prior Authorization Process
  5. Common Denial Reasons
  6. New Jersey Appeals Process
  7. Step-by-Step Approval Guide
  8. Frequently Asked Questions

Coverage Requirements Overview

Cigna requires prior authorization for Stelara (ustekinumab) in New Jersey, with different requirements for intravenous and subcutaneous formulations. The drug must be prescribed by or in consultation with a specialist—gastroenterologist for IBD, dermatologist for psoriasis, or rheumatologist for psoriatic arthritis.

Requirement Details Documentation Needed
Specialist involvement GI, derm, or rheumatology Specialist consultation notes
Step therapy 1-2 preferred biologics first Prior therapy history with dates
TB screening Required before initiation Lab results or chest imaging
Diagnosis coding Specific ICD-10 codes Clinical notes supporting diagnosis
Quantity limits FDA-approved dosing only Weight-based calculations if applicable

ICD-10 Coding and Documentation

Proper ICD-10 coding is essential for Stelara approval. Use the most specific code available and ensure your clinical documentation supports the diagnosis.

Primary ICD-10 Codes for Stelara

Plaque Psoriasis

  • L40.0 - Psoriasis vulgaris (plaque psoriasis)

Psoriatic Arthritis

  • L40.50 - Psoriatic arthropathy, unspecified
  • L40.51 - Distal interphalangeal psoriatic arthropathy
  • L40.52 - Psoriatic arthritis mutilans
  • L40.53 - Psoriatic spondylitis

Inflammatory Bowel Disease

  • K50.x - Crohn's disease (specify site and complications)
  • K51.x - Ulcerative colitis (specify extent and severity)

Documentation Requirements

Your medical records must include:

  • Disease severity (BSA for psoriasis, Mayo/CDAI scores for IBD)
  • Prior treatment failures with specific drug names, doses, and duration
  • Objective findings (photos, endoscopy results, joint assessments)
  • Functional impact on daily activities or work
Tip: Include body surface area (BSA) percentage for psoriasis and validated disease activity scores for IBD to strengthen your case.

HCPCS J-Codes and NDC Numbers

Stelara billing requires specific HCPCS J-codes and NDC numbers depending on the administration route.

Billing Codes

Route HCPCS Code NDC Example Billing Units Modifier
IV J3358 57894-054-27 1 mg = 1 unit JA
Subcutaneous J3357 57894-0060-xx 1 mg = 1 unit JB

Key Billing Details

  • Units calculation: Each 1 mg administered equals 1 billing unit
  • NDC format: Use 11-digit format (5-4-2 sequence) for claims
  • Route modifiers: JA for IV, JB for subcutaneous administration
  • Medical vs. pharmacy benefit: IV typically bills under medical; SC may bill under either
Note: Always verify current NDC numbers with your distributor, as packaging configurations may change.

Prior Authorization Process

Cigna requires completion of their Stelara prior authorization form along with supporting clinical documentation.

Required Documentation

  1. Completed PA form (condition-specific)
  2. Clinical notes from specialist
  3. TB screening results (QuantiFERON or TST plus chest X-ray)
  4. Prior therapy documentation with dates and outcomes
  5. Disease severity assessments (PASI, CDAI, Mayo scores)

Submission Methods

  • Online: Cigna provider portal
  • Fax: Check current fax number on PA form
  • Phone: For expedited reviews (urgent cases)

Timeline: Standard review takes 5-15 business days; expedited review within 72 hours for urgent cases.

Common Denial Reasons

Understanding why Cigna denies Stelara requests helps you prepare stronger appeals.

Denial Reason How to Address
Missing TB screening Submit QuantiFERON and chest X-ray results
Insufficient step therapy Document specific prior biologics with dates, doses, outcomes
Quantity limits exceeded Justify higher dosing with clinical guidelines
Lack of specialist involvement Include consultation notes from appropriate specialist
Missing severity documentation Provide validated disease activity scores

Step Therapy Requirements

For most indications, Cigna requires documented failure of:

  • Psoriasis/PsA: Anti-TNF agents (Humira, Enbrel) or IL-17 inhibitors
  • IBD: Anti-TNF agents or vedolizumab, depending on patient history

"Failure" includes inadequate response, loss of response, or intolerance with documented adverse effects.

New Jersey Appeals Process

If Cigna denies your Stelara request, New Jersey offers robust appeal rights through the Independent Health Care Appeals Program (IHCAP).

Internal Appeals (Required First Step)

  1. First-level internal appeal: 180 days from denial date
  2. Second-level internal appeal: If first level upheld
  3. Timeline: 30 days for standard, 72 hours for expedited

External Review Through IHCAP

After exhausting internal appeals, you can request external review through Maximus Federal Services, which administers New Jersey's IHCAP program.

Key Details:

  • Deadline: 4 months from final internal denial
  • Cost: Free to patients
  • Success rate: Approximately 68% for specialty biologics
  • Timeline: 5 days preliminary review, 45 days final decision
  • Contact: 888-866-6205
From our advocates: "We've seen Cigna reverse denials during the external review process rather than face an official overturn. The key is submitting comprehensive clinical documentation that directly addresses their denial reasons."

Step-by-Step Approval Guide

Step 1: Gather Documentation (Patient/Clinic)

Collect insurance card, prior therapy records, lab results, and specialist notes. Allow 1-2 weeks for complete documentation gathering.

Step 2: Complete TB Screening (Clinic)

Order QuantiFERON-Gold and chest X-ray if not done within 6 months. Results needed before PA submission.

Step 3: Submit Prior Authorization (Clinic)

Use Cigna's current PA form with all supporting documentation. Submit via provider portal or fax. Expected timeline: 5-15 business days.

Step 4: Follow Up (Patient/Clinic)

Check status through Cigna portal. If no response within 15 days, call member services at number on insurance card.

Step 5: Address Denials (Clinic/Patient)

If denied, review denial letter carefully. File internal appeal within 180 days with additional supporting documentation.

Step 6: External Review if Needed (Patient)

After exhausting internal appeals, file IHCAP request with Maximus within 4 months of final denial.

Step 7: Bridge Therapy (Patient)

Request 30-day emergency supply through Accredo while appeals are pending. Counterforce Health can help navigate complex appeal processes and draft evidence-based rebuttal letters.

Frequently Asked Questions

How long does Cigna prior authorization take for Stelara in New Jersey? Standard review takes 5-15 business days. Expedited review for urgent cases is completed within 72 hours.

What if Stelara is non-formulary on my Cigna plan? You can request a formulary exception with clinical justification. Include comparative effectiveness data and specialist support.

Can I get an expedited appeal in New Jersey? Yes, both Cigna internal appeals and IHCAP external reviews offer expedited pathways when delays could seriously jeopardize health.

Does step therapy apply if I failed biologics in another state? Yes, documented biologic failures from any location count toward step therapy requirements if properly documented.

What's the difference between medical and pharmacy benefit for Stelara? IV infusions typically bill under medical benefit (J3358). Subcutaneous injections may bill under either medical or pharmacy benefit depending on site of administration.

How much does Stelara cost without insurance in New Jersey? List price varies by indication and dosing, typically $15,000-25,000 annually. Janssen offers patient assistance programs and copay cards for eligible patients.

Can my doctor file the IHCAP appeal for me? Yes, providers can file external appeals on behalf of patients with written consent. This often expedites the process.

What happens if IHCAP overturns Cigna's denial? The decision is binding. Cigna must provide coverage and implement the decision within 10 business days.

Clinician Corner: Medical Necessity Letter Checklist

When preparing medical necessity documentation for Stelara:

✓ Problem statement: Specific diagnosis with ICD-10 code and disease severity ✓ Prior treatments: List all previous therapies with dates, doses, duration, and outcomes ✓ Clinical rationale: Why Stelara is appropriate for this patient ✓ Guideline citations: Reference FDA labeling and specialty society guidelines ✓ Monitoring plan: How you'll assess treatment response and safety ✓ Contraindications addressed: Why preferred alternatives aren't suitable

Include objective measures like PASI scores for psoriasis, CDAI for Crohn's disease, or joint counts for psoriatic arthritis to strengthen your case.

When to Escalate

Contact the New Jersey Department of Banking and Insurance if you experience:

  • Unreasonable delays in processing
  • Failure to follow appeal timelines
  • Discrimination or unfair practices

NJ DOBI Consumer Hotline: 1-800-446-7467 IHCAP Hotline: 1-888-393-1062

For complex cases involving multiple denials or systemic issues, Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals by analyzing denial letters, plan policies, and clinical notes to identify the specific denial basis and draft point-by-point rebuttals aligned to the plan's own rules.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Always consult with your healthcare provider and insurance plan for specific coverage details. Coverage policies and requirements may change. Verify current information with official sources before making healthcare decisions.

Powered by Counterforce Health—AI that turns drug denials into evidence-based appeals patients and clinicians can submit today.