By Counterforce Health Team in Xyrem (sodium oxybate) —

How to Get Xyrem (Sodium Oxybate) Covered by Cigna in Georgia: Complete Coding and Appeals Guide

Answer Box: Getting Xyrem Covered by Cigna in Georgia

To get Xyrem (sodium oxybate) covered by Cigna in Georgia, you need proper diagnosis codes (G47.411 for narcolepsy with cataplexy), HCPCS J-code J8499, and enrollment in the Xyrem REMS program. Submit prior authorization through Cigna's provider portal or fax (855) 840-1678 with sleep study results showing mean sleep latency ≤8 minutes and documented treatment failures. If denied, file internal appeal within 180 days, then external review with Georgia DOI within 60 days if needed. First step today: Contact your sleep specialist to ensure proper ICD-10 coding and gather required sleep study documentation.

Table of Contents

Medical vs. Pharmacy Benefit Coding

Xyrem (sodium oxybate) is typically covered under the pharmacy benefit since it's an oral solution dispensed through specialty pharmacies. However, proper coding is essential for clean claims processing.

Pharmacy Benefit Path (Most Common):

  • Billed using NDC code 68727-100-01
  • HCPCS J-code J8499 ("Prescription drug, oral, non-chemotherapeutic")
  • Requires REMS enrollment documentation
  • Processed through Cigna's specialty pharmacy network (often Express Scripts/Accredo)

Medical Benefit Path (Rare):

  • Only applicable if administered in clinical setting
  • Would use CPT code 96372 for therapeutic administration
  • Not typical for Xyrem since it's self-administered at home
Note: Xyrem is distributed exclusively through the Xyrem/Xywav Success Program REMS, which requires both prescriber and patient enrollment before dispensing.

ICD-10 Diagnosis Codes for Narcolepsy

Proper diagnosis coding is critical for Cigna approval. Use these specific ICD-10 codes based on your patient's presentation:

ICD-10 Code Diagnosis Documentation Required
G47.411 Narcolepsy with cataplexy Documented cataplexy episodes, MSLT ≤8 minutes, ≥2 SOREMPs
G47.419 Narcolepsy without cataplexy MSLT ≤8 minutes, ≥2 SOREMPs, no cataplexy
G47.429 Narcolepsy in conditions classified elsewhere Secondary narcolepsy with underlying condition coded separately

Key Documentation Words That Support Coding:

  • "Irrepressible need to sleep occurring daily"
  • "Mean sleep latency of [X] minutes on MSLT"
  • "Sleep-onset REM periods (SOREMPs) documented on [date]"
  • "Failed trial of [specific medication] due to [reason]"
  • "Cataplexy triggered by [emotional stimulus]"
Clinician Corner: Cigna requires that narcolepsy diagnosis be confirmed through sleep testing showing mean sleep latency ≤8 minutes and ≥2 SOREMPs on MSLT following nocturnal PSG that rules out other causes.

Product Coding: HCPCS, NDC, and Units

Primary Codes for Xyrem:

  • NDC: 68727-100-01 (180 mL bottle, sodium oxybate 500 mg/mL)
  • HCPCS: J8499 ("Prescription drug, oral, non-chemotherapeutic")
  • Manufacturer: Jazz Pharmaceuticals, Inc.

Dosing Units and Conversion: Xyrem dosing can create billing confusion due to gram-to-milliliter conversions:

  • Starting dose: 4.5 g per night (divided into two 2.25 g doses)
  • Therapeutic range: 6-9 g per night
  • Maximum: 9 g per night for twice-nightly dosing

Units Math Example:

  • Patient prescribed 6 g per night
  • 6 g ÷ 0.5 g/mL = 12 mL per night
  • Monthly supply: 12 mL × 30 nights = 360 mL (2 bottles)
Tip: Always verify whether your e-prescribing system requires dosing in grams or milliliters. Mismatched units are a common cause of quantity limit rejections.

Clean Prior Authorization Request

Here's the anatomy of a successful Xyrem prior authorization for Cigna:

Required Clinical Documentation

  1. Sleep Study Results:
    • Nocturnal polysomnography (PSG) ruling out other causes
    • Multiple Sleep Latency Test (MSLT) showing mean sleep latency ≤8 minutes
    • Documentation of ≥2 sleep-onset REM periods (SOREMPs)
  2. Treatment History:
    • For Type 1 narcolepsy: Failed trial of tricyclic antidepressants (amitriptyline, desipramine, imipramine) OR SSRIs (fluoxetine, sertraline, paroxetine) OR venlafaxine
    • Documentation of inadequate response or intolerance
  3. Prescriber Requirements:
    • Must be prescribed by neurologist, pulmonologist, or sleep specialist
    • REMS program enrollment confirmation

Submission Methods

  • Online: Cigna provider portal (verify current link)
  • Fax: (855) 840-1678
  • EHR: SureScripts integration where available

Expected Timeline: 5 business days for standard requests; expedited available by calling (800) 882-4462.

Common Coding Pitfalls

Pitfall Impact Fix
Wrong ICD-10 code Automatic denial Use G47.411 for narcolepsy with cataplexy, G47.419 without
Missing REMS documentation Claim rejection Include REMS enrollment confirmation for both prescriber and patient
Unit conversion errors Quantity limit rejection Double-check gram-to-mL conversion: 1 g = 2 mL for Xyrem
Incomplete sleep studies Medical necessity denial Must include both PSG and MSLT results with specific timing criteria
Wrong prescriber specialty PA denial Ensure prescription is from neurologist, pulmonologist, or sleep specialist

Cigna Verification Process

Before submitting your prior authorization:

  1. Check Formulary Status: Verify Xyrem's tier placement on your patient's specific Cigna plan
  2. Confirm PA Requirements: Call Cigna provider services to confirm current PA criteria
  3. Verify Specialty Pharmacy: Confirm which specialty pharmacy is preferred (often Express Scripts/Accredo)
  4. Review Medical Policy: Check Cigna's oxybate coverage policy for updates

Appeals Process in Georgia

If your Xyrem prior authorization is denied, Georgia provides a structured appeals pathway:

Internal Appeal (Level 1)

  • Deadline: 180 days from denial date
  • Timeline: 30 days for standard review, 72 hours if expedited
  • How to file: Through Cigna member/provider portal or written request
  • Required documents: Original PA request, denial letter, additional clinical evidence

External Review (Georgia DOI)

  • Deadline: 60 days from final internal denial
  • Cost: Free to consumer
  • Timeline: 30 business days (standard) or 72 hours (expedited)
  • How to file: Submit application to Georgia Office of Commissioner of Insurance and Fire Safety
  • Contact: Georgia DOI Consumer Services at 1-800-656-2298
Georgia-Specific Rights: Under Georgia's Healthcare Consumer's Utility and Billing Appeals Act, external review decisions are binding on insurers. You can request expedited external review concurrent with internal appeal if delay poses serious risk.

When dealing with complex prior authorization challenges like Xyrem, many patients and providers turn to specialized services. Counterforce Health helps patients, clinicians, and specialty pharmacies get prescription drugs approved by turning insurance denials into targeted, evidence-backed appeals. Their platform ingests denial letters, plan policies, and clinical notes to identify the specific denial basis and draft point-by-point rebuttals aligned to each plan's requirements.

From Our Advocates

We've seen Xyrem appeals succeed when providers emphasize the FDA orphan drug designation (since July 2019) and include detailed sleep study metrics that clearly meet Cigna's specific thresholds. One effective strategy is requesting a peer-to-peer review with Cigna's medical director, usually scheduled within 72 hours, where the sleep specialist can directly explain why alternatives have failed and why Xyrem is medically necessary for this specific patient.

Pre-Submission Checklist

Before submitting your Xyrem prior authorization to Cigna:

Clinical Documentation:

  • ICD-10 code matches diagnosis (G47.411 or G47.419)
  • Sleep study results include PSG and MSLT with specific metrics
  • Prior treatment failures documented with dates and reasons
  • Prescriber is neurologist, pulmonologist, or sleep specialist

Coding and Billing:

  • NDC code 68727-100-01 confirmed
  • HCPCS J8499 included
  • Dosing units consistent (grams vs. mL)
  • Quantity calculation verified for monthly supply

REMS Requirements:

  • Prescriber enrolled in Xyrem/Xywav Success Program
  • Patient enrolled in REMS program
  • Enrollment documentation attached

Submission Details:

  • Correct fax number or portal confirmed
  • All required forms completed
  • Contact information current for follow-up

FAQ

How long does Cigna prior authorization take for Xyrem in Georgia? Standard requests take 5 business days. Expedited requests are available by calling (800) 882-4462 and can be processed within 72 hours if medical urgency is documented.

What if Xyrem is non-formulary on my Cigna plan? You can request a formulary exception with clinical justification showing medical necessity and why formulary alternatives are inappropriate or have failed.

Can I request an expedited appeal in Georgia? Yes. Georgia allows expedited internal appeals (72 hours) and expedited external review (72 hours) if delay would seriously jeopardize your health or ability to regain maximum function.

Does step therapy apply if I've tried medications outside Georgia? Yes, documented treatment failures from any location count toward step therapy requirements, as long as you have proper documentation of the trial and reason for discontinuation.

What counts as medical necessity for Xyrem? Cigna requires confirmed narcolepsy diagnosis through sleep testing, documented treatment failures, and prescription by appropriate specialist.

How do I get help with the appeals process in Georgia? Contact Georgia DOI Consumer Services at 1-800-656-2298 or use their online complaint form. Georgians for a Healthy Future also provides consumer assistance with insurance appeals.

What if my sleep study was done years ago? Cigna may accept older sleep studies if they meet current diagnostic criteria, but recent studies (within 2-3 years) are preferred. Check with your sleep specialist about whether repeat testing is recommended.

Can I appeal to an independent reviewer in Georgia? Yes, after exhausting internal appeals, you can request external review through the Georgia DOI. This involves independent physicians reviewing your case, and their decision is binding on Cigna.

For complex cases involving multiple denials or unusual circumstances, services like Counterforce Health can help analyze your specific situation and develop targeted appeal strategies based on your plan's exact requirements and your clinical history.

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 plan benefits, medical circumstances, and current policies. Always consult with your healthcare provider and contact your insurance company directly for plan-specific requirements. For assistance with insurance appeals in Georgia, contact the Georgia Department of Insurance Consumer Services Division.

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