By Counterforce Health Team in Tecentriq (atezolizumab) —

How to Get Tecentriq (Atezolizumab) Covered by Cigna in Virginia: Appeals Process and Forms

Quick Answer: Getting Tecentriq Covered by Cigna in Virginia

Tecentriq (atezolizumab) requires prior authorization from Cigna in Virginia. If denied, you have strong appeal rights through Virginia's external review process. Start today: Contact your oncologist to submit a PA request via CoverMyMeds or call Cigna at the number on your insurance card. If denied, you have 180 days to appeal internally, then 120 days for external review through Virginia's Bureau of Insurance. Most oncology denials are overturned with proper clinical documentation and biomarker testing results.

First step: Have your doctor gather your cancer diagnosis, staging, PD-L1 testing (if done), and prior treatment history before submitting the PA request.

Table of Contents

  1. Understanding Cigna's Tecentriq Coverage
  2. Reading Your Denial Letter
  3. Common Fixable Causes
  4. First-Level Internal Appeal
  5. Peer-to-Peer Review Process
  6. Virginia External Review Process
  7. Appeal Letter Templates
  8. Tracking Your Case
  9. When All Else Fails
  10. FAQ

Understanding Cigna's Tecentriq Coverage

Cigna covers Tecentriq (atezolizumab) for FDA-approved indications including non-small cell lung cancer (NSCLC), small cell lung cancer, hepatocellular carcinoma, and select other cancers. However, prior authorization is required for all specialty oncology medications.

Coverage at a Glance

Requirement What It Means Where to Find It Source
Prior Authorization Doctor must get approval before prescribing Cigna PA forms Cigna Policy
Formulary Status Covered on specialty tier Cigna formulary Plan documents
Specialty Pharmacy Must use Accredo or approved network Cigna specialty pharmacy Member guide
Biomarker Testing PD-L1 testing may be required for NSCLC FDA label requirements FDA Access Data
Appeal Deadline 180 days for internal appeals Plan policy Standard coverage

Reading Your Denial Letter

When Cigna denies Tecentriq, your denial letter will include specific reason codes. Here's how to decode them:

Common denial reasons:

  • "Not medically necessary" - Clinical criteria not met
  • "Experimental/investigational" - Off-label use not covered
  • "Step therapy required" - Must try other drugs first
  • "Non-formulary" - Not on preferred drug list
  • "Quantity limits exceeded" - Dosing frequency issues
Important: Your denial letter must include the specific clinical criteria that weren't met and your right to appeal. If this information is missing, contact Cigna immediately.

Extract these key details:

  1. Appeal deadline (usually 180 days from denial date)
  2. Clinical reason for denial
  3. Required documentation for appeal
  4. Contact information for appeals

Common Fixable Causes

Many Tecentriq denials can be resolved by addressing simple documentation issues:

Missing Documentation

  • Lab results: PD-L1 testing, staging scans, biomarker reports
  • Prior treatment history: Documentation of failed therapies
  • Diagnosis codes: Correct ICD-10 codes for your cancer type
  • Clinical notes: Oncologist's treatment rationale

Coding Issues

  • Wrong J-code: Tecentriq uses J9022 for billing
  • Incorrect diagnosis: Ensure ICD-10 matches FDA-approved indication
  • Site of care: Infusion center vs. hospital outpatient coding

Policy Misunderstanding

  • Step therapy confusion: Not always required for first-line cancer treatment
  • Off-label use: May be covered with strong clinical justification

First-Level Internal Appeal

Virginia law requires Cigna to provide a fair internal appeals process. Here's your step-by-step approach:

Step 1: Gather Required Documents

  • Original denial letter
  • Complete medical records
  • PD-L1 testing results (if applicable)
  • Staging documentation
  • Prior treatment records
  • Oncologist's letter of medical necessity

Step 2: Submit Your Appeal

Timeline: Within 180 days of denial Method: Online portal, mail, or fax Required: Signed appeal form and supporting documentation

Medical Necessity Letter Checklist

Your oncologist should include:

  • ✅ Specific cancer diagnosis and stage
  • ✅ Why Tecentriq is medically necessary
  • ✅ Prior treatments tried and outcomes
  • ✅ Relevant clinical guidelines (NCCN, ASCO)
  • ✅ Expected treatment outcomes
  • ✅ Risks of treatment delay
Clinician Corner: Reference NCCN Guidelines and FDA labeling in your medical necessity letter. Include specific page numbers and version dates for stronger appeals.

Peer-to-Peer Review Process

If your initial appeal is denied, request a peer-to-peer review where your oncologist speaks directly with Cigna's medical director.

Scheduling the Call

  1. Request within 30 days of appeal denial
  2. Call Cigna provider services (number on denial letter)
  3. Ask for oncology specialist reviewer when possible

Preparation Checklist

  • Clinical timeline: Diagnosis, staging, prior treatments
  • Guideline references: NCCN, ASCO recommendations
  • Patient-specific factors: Contraindications, comorbidities
  • Treatment goals: Response expectations, quality of life

Key Talking Points

  • Emphasize FDA approval for your indication
  • Discuss failed prior therapies and contraindications
  • Reference published clinical trial data
  • Explain urgency of treatment initiation

Virginia External Review Process

If Cigna upholds their denial after internal appeals, Virginia's external review process provides an independent second opinion.

Eligibility Requirements

  • ✅ Completed Cigna's internal appeals process
  • ✅ Virginia-issued health plan (or opted-in self-funded plan)
  • ✅ Denial based on medical necessity or experimental treatment
  • ✅ Request filed within 120 days of final internal denial

How to Request External Review

Contact Virginia Bureau of Insurance first: Call (877) 310-6560 for guidance before submitting your request.

Required Form: Form 216-A External Review Request (verify current form with Bureau)

Supporting Documents:

  • Final denial letter from Cigna
  • All medical records
  • Oncologist's statement
  • Any additional clinical evidence

Timeline and Process

  • Standard review: 45 days for decision
  • Expedited review: 72 hours for urgent medical situations
  • Independent reviewer: Board-certified oncologist when possible
  • Binding decision: Cigna must comply if overturned
Virginia Advantage: Virginia allows expedited external review for cancer treatment denials without exhausting all internal appeals in urgent situations.

Contact Information:

  • Virginia Bureau of Insurance: (877) 310-6560
  • Managed Care Ombudsman: (804) 371-9032
  • Consumer Services: Available Monday-Friday, 8:30 AM - 5:00 PM

Appeal Letter Templates

Patient Appeal Script (Phone)

"Hello, I'm calling to appeal the denial of Tecentriq for my [cancer type]. My denial reference number is [number]. Can you please send me the appeal forms and tell me exactly what documentation you need? I'd also like to know the deadline for submitting my appeal."

Medical Necessity Letter Outline

Dear [Cigna Medical Director],

I am writing to request coverage for Tecentriq (atezolizumab) for my patient [Name], DOB [Date], Member ID [Number].

CLINICAL BACKGROUND:
- Diagnosis: [Specific cancer type and stage]
- Date of diagnosis: [Date]
- Current performance status: [ECOG score if available]

TREATMENT HISTORY:
- Prior therapies: [List with dates and outcomes]
- Contraindications: [Any drugs patient cannot take]
- Response to treatment: [Include imaging if available]

MEDICAL NECESSITY:
- FDA indication: [Cite specific approved use]
- Clinical guidelines: [Reference NCCN, ASCO recommendations]
- Expected benefit: [Treatment goals and timeline]

REQUEST:
I respectfully request immediate approval for Tecentriq as medically necessary treatment for this patient.

Sincerely,
[Oncologist name and credentials]

Tracking Your Case

Appeal Log Template

Keep detailed records of all communications:

Date Contact Method Person Spoken To Reference Number Outcome Next Step
[Date] Phone [Name] [Ref #] [Result] [Action]

Key Deadlines to Track

  • Internal appeal deadline: 180 days from denial
  • External review deadline: 120 days from final internal denial
  • Expedited review: Available for urgent medical situations
  • Follow-up calls: Every 10-15 business days during review

When All Else Fails

If your appeals are unsuccessful, you still have options:

Alternative Coverage Paths

  • Formulary exception request: For non-formulary status
  • Medical exception: For unique clinical circumstances
  • Employer appeal: If you have employer-sponsored insurance

Financial Assistance

  • Genentech patient assistance: Genentech Access Solutions
  • Cancer support organizations: Financial assistance programs
  • Hospital charity care: Reduced-cost treatment programs
  • Virginia Poverty Law Center: Health assistance program
  • Counterforce Health: Specializes in turning insurance denials into successful appeals by analyzing denial letters and crafting evidence-backed rebuttals aligned with payer policies
  • Patient advocacy groups: Cancer-specific organizations
From our advocates: "We've seen many Tecentriq denials overturned when patients provide complete biomarker testing and staging documentation. The key is often getting PD-L1 results and clear documentation of why other treatments aren't suitable. Don't give up after the first denial—Virginia's external review process has helped many cancer patients get coverage."

FAQ

How long does Cigna prior authorization take for Tecentriq? Standard PA review takes 5-7 business days. Urgent requests can be expedited with physician certification of medical urgency.

What if Tecentriq is non-formulary on my Cigna plan? You can request a formulary exception with clinical justification. Your oncologist will need to demonstrate medical necessity and why formulary alternatives aren't suitable.

Can I request expedited appeal in Virginia? Yes, if your oncologist certifies that waiting for standard review could jeopardize your health. Expedited external reviews are decided within 72 hours.

Does step therapy apply to cancer treatments? Step therapy requirements vary by plan, but many cancer treatments are exempt from step therapy due to the urgency of care. Check your specific plan documents.

What happens if I start treatment before approval? You may be responsible for the full cost. However, some patients proceed with treatment and seek reimbursement through appeals. Discuss with your oncologist and insurance company.

How much does Tecentriq cost without insurance? List prices range from approximately $8,113 for 840mg vials to $11,589 for 1200mg vials, according to wholesale acquisition cost data.

Can I get help with the appeals process? Yes, contact Virginia's Managed Care Ombudsman at (877) 310-6560 for free assistance with appeals and external review requests.

Sources & Further Reading

This article is for informational purposes only and does not constitute medical or legal advice. Always consult with your healthcare provider and insurance company for guidance specific to your situation. For professional assistance with insurance appeals, consider services like Counterforce Health that specialize in evidence-based appeal strategies.

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