By Counterforce Health Team in Crysvita (burosumab) —

Myths vs. Facts: Getting Crysvita (Burosumab) Covered by Cigna in Florida - Appeals Guide 2024

Answer Box: Your Path to Crysvita Coverage in Florida

Myth-busting fact: Cigna covers Crysvita (burosumab) for X-linked hypophosphatemia (XLH) with proper documentation, not automatic denials. Requirements: genetic confirmation (PHEX mutation) or biochemical evidence (elevated FGF23 + low phosphate), specialist prescriber, baseline labs, and prior therapy documentation for adults. Fastest path: Submit complete prior authorization through Cigna's provider portal with endocrinologist support. If denied: File internal appeal within 180 days, then Florida external review within 4 months through Department of Financial Services. First step today: Contact your specialist to gather genetic test results and baseline phosphate/FGF23 levels.

Table of Contents

  1. Why Myths About Crysvita Coverage Persist
  2. Myth vs. Fact: The Truth About Cigna Coverage
  3. What Actually Influences Approval
  4. Avoid These Critical Mistakes
  5. Quick Action Plan: Three Steps to Take Today
  6. Florida Appeals Process
  7. Resources and Support

Why Myths About Crysvita Coverage Persist

Misinformation about Crysvita (burosumab) coverage runs rampant in patient communities, often leaving families discouraged before they even start the approval process. These myths persist because rare disease treatments like Crysvita carry high costs—up to $13,354 per vial—and involve complex specialty pharmacy workflows that seem intimidating.

The reality? Cigna has clear, documented pathways for Crysvita approval when clinical criteria are met. Understanding the facts can mean the difference between giving up and getting life-changing treatment for X-linked hypophosphatemia (XLH).

Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals by identifying the specific denial basis and crafting point-by-point rebuttals aligned to each plan's own rules. Their platform helps patients and clinicians navigate these exact scenarios with payer-specific workflows and documentation requirements.

Myth vs. Fact: The Truth About Cigna Coverage

Myth 1: "Cigna automatically denies all expensive rare disease drugs"

Fact: Cigna covers Crysvita when clinical criteria are met. Their policy specifically outlines approval pathways for both XLH and tumor-induced osteomalacia (TIO). The key is complete documentation, not cost alone.

Myth 2: "If my doctor prescribes it, insurance has to cover it"

Fact: Prescriptions don't guarantee coverage. Cigna requires prior authorization with specific documentation: genetic confirmation (PHEX mutation), biochemical evidence (elevated FGF23 and low serum phosphate), and specialist attestation. Missing any element triggers denial.

Myth 3: "You must fail oral phosphate and vitamin D first"

Fact: For adults, Cigna requires documentation of prior inadequate response or intolerance to oral phosphate and active vitamin D analogs, but this doesn't mean lengthy trials if contraindications exist. Pediatric patients (≥6 months) don't face the same step therapy requirements.

Myth 4: "Appeals never work for expensive medications"

Fact: Multiple patients have successfully overturned Crysvita denials through both internal and external appeals, especially when comprehensive clinical documentation and specialist support are provided. Success rates improve significantly with targeted, evidence-based appeals.

Myth 5: "Specialty pharmacies make the process impossible"

Fact: Cigna's specialty pharmacy partner (typically Accredo through Express Scripts) streamlines Crysvita delivery once approved. The challenge is getting initial authorization, not the dispensing process.

Myth 6: "Genetic testing isn't really required"

Fact: For XLH, Cigna explicitly requires either genetic confirmation of PHEX mutation or biochemical evidence (elevated FGF23 plus low phosphate). Clinical suspicion alone won't secure approval.

What Actually Influences Approval

Based on Cigna's coverage policy, approval hinges on these documented factors:

Clinical Documentation Requirements:

  • Confirmed XLH diagnosis via genetic testing (PHEX mutation) or biochemical evidence
  • Specialist prescriber (endocrinologist, nephrologist, or metabolic bone specialist)
  • Baseline laboratory values (serum phosphate, FGF23, kidney function)
  • Treatment history with conventional therapy for adults
  • Weight-based dosing justification per FDA labeling

Administrative Factors:

  • Complete prior authorization forms submitted through correct channels
  • Proper coding and pharmacy network compliance
  • Timely submission within plan deadlines
  • Clear documentation of medical necessity

Provider Credentialing:

  • Specialist must be in-network or have prior approval for out-of-network care
  • Prescriber must have experience with XLH management
  • Clinical notes must demonstrate ongoing monitoring plan

Avoid These Critical Mistakes

1. Incomplete Genetic/Biochemical Documentation

The mistake: Submitting prior authorization without genetic test results or complete biochemical evidence.

The fix: Ensure you have either confirmed PHEX mutation results or documented elevated FGF23 levels plus low serum phosphate before submission.

2. Wrong Prescriber Type

The mistake: Having a primary care physician or general pediatrician submit the request.

The fix: Work with an endocrinologist, nephrologist, or metabolic bone disease specialist who understands XLH management and Cigna's requirements.

3. Missing Prior Therapy Documentation

The mistake: For adults, failing to document previous treatment with oral phosphate and active vitamin D analogs.

The fix: Provide detailed records of prior therapy trials, including doses, duration, response, and reasons for discontinuation or intolerance.

4. Incomplete Baseline Labs

The mistake: Submitting requests without complete baseline laboratory values.

The fix: Include recent serum phosphate, FGF23, calcium, parathyroid hormone, and kidney function tests with your submission.

5. Delayed Appeal Filing

The mistake: Missing Florida's appeal deadlines (180 days for internal, 4 months for external review).

The fix: Calendar all deadlines immediately upon receiving denial and gather appeal documentation promptly.

From our advocates: We've seen patients successfully overturn initial denials by working closely with their endocrinologist to compile comprehensive genetic testing, baseline labs, and detailed prior therapy records. The key is treating the prior authorization as a clinical case presentation rather than just a form to fill out.

Quick Action Plan: Three Steps to Take Today

Step 1: Gather Essential Documentation (Today)

Contact your specialist's office to collect:

  • Genetic test results confirming PHEX mutation (or request testing if not done)
  • Recent lab results: serum phosphate, FGF23, calcium, PTH, kidney function
  • Documentation of prior phosphate/vitamin D therapy (adults)
  • Current weight and dosing calculations

Step 2: Verify Cigna Requirements (This Week)

  • Download current Cigna prior authorization forms
  • Confirm your specialist is in-network or obtain out-of-network approval
  • Verify Accredo is your designated specialty pharmacy
  • Check if expedited review applies to your situation

Step 3: Submit Complete Package (Within 2 Weeks)

Work with your specialist to submit:

  • Completed prior authorization form with all required signatures
  • Clinical letter detailing medical necessity
  • All supporting laboratory and genetic documentation
  • Prior therapy records and monitoring plan

Florida Appeals Process

If Cigna denies your Crysvita request, Florida provides a structured appeals pathway:

Internal Appeals (First Level)

  • Deadline: 180 days from denial notice
  • Timeline: 30 days for standard review, 72 hours for expedited
  • Submission: Through Cigna member portal or written request
  • Required: Original denial letter, additional clinical documentation, specialist letter

External Review (Independent)

  • Deadline: 4 months after final internal denial
  • Process: Independent medical review through Florida Department of Financial Services
  • Cost: Free to patients
  • Contact: 1-877-693-5236
  • Binding: Decision is final and must be honored by Cigna

Expedited Reviews

  • Available for urgent medical situations
  • 72-hour timeline for both internal and external reviews
  • Requires documentation of immediate medical necessity

For comprehensive support navigating these appeals, Counterforce Health helps patients and clinicians identify specific denial reasons and craft targeted rebuttals using payer-specific workflows and evidence requirements.

Resources and Support

Official Cigna Resources:

Florida State Resources:

Patient Support:

  • Kyowa Kirin Cares (manufacturer patient assistance program)
  • Counterforce Health (appeals assistance)
  • XLH Network (patient advocacy organization)

Clinical Guidelines:

Disclaimer: This information is for educational purposes and does not constitute medical or legal advice. Coverage decisions depend on individual circumstances and plan specifics. Always consult with your healthcare provider and insurance company for personalized guidance. For official appeals assistance in Florida, contact the Department of Financial Services at 1-877-693-5236.

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