By Counterforce Health Team in StrataGraft (allogeneic cultured keratinocytes & fibroblasts in murine collagen-dsat) —

How to Get StrataGraft Approved by Cigna in Illinois: Complete Prior Authorization & Appeals Guide

Answer Box: Getting StrataGraft Covered by Cigna in Illinois

StrataGraft requires prior authorization from Cigna in Illinois and is covered under the medical benefit using HCPCS code J7353. The fastest path to approval: (1) Confirm deep partial-thickness thermal burn diagnosis with proper ICD-10 coding, (2) Submit PA request via Cigna provider portal or fax to 1-866-873-8279 with clinical documentation, and (3) Include wound measurements, failed standard care documentation, and burn specialist attestation. If denied, Illinois law provides strong external review rights within 120 days of final denial through the Illinois Department of Insurance.

Table of Contents

  1. What This Guide Covers
  2. Before You Start: Verify Your Coverage
  3. Gather Required Documentation
  4. Submit Your Prior Authorization Request
  5. Follow-Up and Timeline Expectations
  6. Handling Medical Necessity Questions
  7. If Your Request Is Denied
  8. Illinois External Review Process
  9. Renewal and Re-Authorization
  10. Quick Reference Checklist
  11. FAQ

What This Guide Covers

This guide helps patients with deep partial-thickness thermal burns and their healthcare providers navigate Cigna's prior authorization process for StrataGraft in Illinois. StrataGraft (allogeneic cultured keratinocytes and fibroblasts in murine collagen-dsat) is an FDA-approved tissue-engineered treatment manufactured by Mallinckrodt for adults with thermal burns where surgical intervention is clinically indicated.

Who this helps:

  • Patients with Cigna coverage in Illinois needing StrataGraft
  • Healthcare providers submitting PA requests
  • Caregivers navigating insurance appeals
Note: This is not medical advice. Always consult with your healthcare provider about treatment options and work with your insurance company for coverage decisions.

Before You Start: Verify Your Coverage

Coverage Basics

Medical Benefit Only: StrataGraft is billed under your medical benefit using HCPCS code J7353, not as a prescription drug. This means it's processed through your medical insurance, not pharmacy benefits.

Prior Authorization Required: Cigna mandates precertification for StrataGraft. Submit requests with detailed clinical documentation.

Verify Your Plan Details

  1. Check your member ID card for plan type (PPO, HMO, etc.)
  2. Confirm in-network provider status for your burn specialist
  3. Review your Summary of Benefits for surgical coverage details
  4. Call Cigna Member Services at 1-800-88CIGNA (882-4462) to verify PA requirements

Gather Required Documentation

Essential Clinical Documentation

Diagnosis Requirements:

  • ICD-10 codes for deep partial-thickness thermal burns (T21-T25 series)
  • Burn depth confirmation with clinical assessment
  • Wound measurements and photographic evidence
  • Total body surface area (TBSA) percentage affected

Medical Necessity Evidence:

  • Burn specialist consultation and recommendation
  • Documentation of surgical indication
  • Failed standard wound care attempts (if applicable)
  • Patient age verification (18+ years required)
  • Allergy screening (no bovine/porcine allergies)
Clinician Corner: Your medical necessity letter should include: (1) confirmed deep partial-thickness burn diagnosis, (2) wound bed measurements justifying construct quantity, (3) clinical rationale for surgical intervention, and (4) attestation that StrataGraft is appropriate for this specific burn type per FDA labeling.

Documentation Checklist

  • Office chart notes with burn assessment
  • Clinical photographs of wound site
  • Lab results (if relevant to treatment)
  • Prior therapy documentation
  • Wound measurement records
  • Burn specialist attestation letter

Submit Your Prior Authorization Request

Submission Methods

Primary Options:

  • Provider Portal: Submit through Cigna's online provider system
  • Fax: 1-866-873-8279
  • Phone: 1-800-88CIGNA (882-4462) for assistance

Clean Request Packet Requirements

  1. Completed PA form with all required fields
  2. Clinical documentation supporting medical necessity
  3. HCPCS code J7353 with quantity justification
  4. ICD-10 diagnosis codes for burn location and depth
  5. Provider NPI and facility information
  6. Patient demographics and insurance details
Tip: Only one entity (facility or physician) should bill J7353 to avoid duplicate claims issues.

Follow-Up and Timeline Expectations

Illinois-Specific Timelines

Standard Prior Authorization:

  • Cigna response time: 15 business days for non-urgent requests
  • Expedited reviews: 24 hours when delay would jeopardize health
  • Follow-up recommended: After 10 business days if no response

What to Track

  • Reference number from your submission
  • Submission date and method used
  • Contact person at Cigna (if assigned)
  • Additional information requests and response deadlines

Sample Follow-Up Script: "I'm calling about prior authorization request #[reference number] for StrataGraft submitted on [date]. Can you provide a status update and let me know if any additional information is needed?"

Handling Medical Necessity Questions

Common Information Requests

Clinical Clarifications:

  • Burn depth assessment methodology
  • Wound healing progression documentation
  • Alternative treatment considerations
  • Surgical timing rationale

Documentation Supplements:

  • Additional clinical photographs
  • Specialist consultation notes
  • Treatment timeline documentation
  • Patient-specific contraindications

Strengthening Your Case

Include references to:

  • FDA labeling for StrataGraft's approved indication
  • Burn treatment guidelines from recognized medical societies
  • Clinical evidence supporting tissue-engineered therapies
  • Patient-specific factors favoring StrataGraft over alternatives

If Your Request Is Denied

Common Denial Reasons & Solutions

Denial Reason How to Address
Insufficient documentation Submit additional clinical notes, photos, measurements
Not medically necessary Provide burn specialist letter with clinical rationale
Alternative treatments available Document contraindications or failures of alternatives
Coding issues Verify correct HCPCS/ICD-10 codes with billing department

Internal Appeal Process

Timeline: You have 180 days from denial date to file internal appeal with Cigna.

Required Elements:

  • Written appeal letter explaining medical necessity
  • Additional clinical documentation
  • Specialist recommendations
  • Patient impact statement (optional)

Submission Methods:

  • Cigna member/provider portal
  • Written appeal to address on denial letter
  • Fax to number specified in denial notice

Illinois External Review Process

Your Rights Under Illinois Law

Illinois provides robust external review rights under the Health Carrier External Review Act. After completing Cigna's internal appeal process, you can request an independent medical review.

Key Protections:

  • 120-day filing window from final internal denial
  • Independent physician reviewer with relevant expertise
  • Binding decision on Cigna if overturned
  • No cost to patient (Cigna pays review fees)

How to Request External Review

  1. Contact Illinois Department of Insurance at (877) 527-9431
  2. Complete external review application
  3. Submit within 120 days of final adverse determination
  4. Provide all medical records and supporting documentation

Expedited External Review: Available when delay would seriously jeopardize your health, with decisions in 24-72 hours.

From Our Advocates: We've seen Illinois external reviews succeed when patients provide comprehensive burn specialist documentation showing StrataGraft meets FDA-approved criteria that standard treatments cannot address. The independent physician reviewers appreciate detailed wound assessments and clear surgical rationale.

Renewal and Re-Authorization

When Re-Authorization Is Needed

StrataGraft is typically approved for one-time application only per thermal burn occurrence. Re-authorization may be needed for:

  • Different burn sites requiring separate treatment
  • Complications requiring additional intervention
  • Extended treatment courses (rare, case-by-case basis)

Renewal Documentation

  • Current wound assessment and healing progress
  • Clinical justification for continued/additional treatment
  • Updated photographs and measurements
  • Treatment response documentation

Quick Reference Checklist

Before Submitting:

  • Confirm deep partial-thickness burn diagnosis
  • Verify burn specialist recommendation
  • Gather wound measurements and photos
  • Check patient age (18+ required)
  • Screen for bovine/porcine allergies
  • Obtain clinical notes and lab results

Submission Packet:

  • Completed PA form
  • Medical necessity letter
  • HCPCS J7353 with quantity justification
  • Appropriate ICD-10 codes
  • Clinical documentation
  • Specialist attestation

After Submission:

  • Track reference number
  • Follow up after 10 business days
  • Respond promptly to information requests
  • Prepare appeal materials if needed

Frequently Asked Questions

How long does Cigna prior authorization take in Illinois? Standard requests receive responses within 15 business days. Expedited reviews are completed within 24 hours when medically urgent.

What if StrataGraft is considered non-formulary? StrataGraft is billed under medical benefits (HCPCS J7353), not pharmacy benefits, so formulary status doesn't apply. Medical necessity is the key coverage criterion.

Can I request an expedited appeal in Illinois? Yes, both Cigna internal appeals and Illinois external reviews offer expedited pathways when delay would seriously jeopardize your health.

What documentation strengthens my case? Burn specialist attestation, detailed wound measurements, clinical photographs, and clear documentation that standard treatments are insufficient or contraindicated.

How much does external review cost in Illinois? External reviews are free to patients. Cigna pays all review fees under Illinois law.

What if my burn specialist isn't in-network with Cigna? Out-of-network specialists can still provide StrataGraft if you obtain prior authorization, though your out-of-pocket costs may be higher.

Getting Help with Your Appeal

When dealing with complex prior authorization and appeal processes, having expert support can make a significant difference. Counterforce Health specializes in helping patients, clinicians, and specialty pharmacies turn insurance denials into successful, evidence-backed appeals. Their platform analyzes denial letters and plan policies to create targeted rebuttals that align with each payer's specific requirements, potentially saving you time and improving your chances of approval.

For additional assistance, contact:

  • Illinois Department of Insurance Office of Consumer Health Insurance: (877) 527-9431
  • Illinois Attorney General Health Care Helpline: 1-877-305-5145
  • Cigna Member Services: 1-800-88CIGNA (882-4462)

Sources & Further Reading

Disclaimer: This guide provides general information about insurance coverage and appeals processes. It is not medical advice, legal advice, or a guarantee of coverage approval. Always consult with your healthcare provider about treatment decisions and work directly with your insurance company for coverage determinations. Coverage policies and procedures may change; verify current requirements with your insurer and state regulators.

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