How long does Cigna take to process Krystexxa renewal requests?

Standard Cigna decisions for Krystexxa renewals take up to 15 business days. Urgent requests may be processed faster if marked as such and submitted within 7 days of authorization expiration.

What documentation is required for Krystexxa renewal with Cigna?

Required documentation includes recent serum uric acid lab results showing response (typically <6 mg/dL), rheumatology progress notes demonstrating continued medical necessity, and documentation of prior failures with allopurinol and febuxostat.

When should I submit my Krystexxa renewal request to Cigna?

Submit your Krystexxa renewal request 2-4 weeks before your current authorization expires to ensure continuity of coverage. If submitting within 7 days of expiration, mark the request as urgent.

What if my Krystexxa renewal is denied by Cigna?

If your Krystexxa renewal is denied by Cigna, you can file an appeal with additional clinical documentation, peer-to-peer review requests, or external review through California's independent review process if internal appeals are exhausted.

By Counterforce Health Team in Krystexxa (pegloticase) — 07 Dec 2025

Renewing Krystexxa (Pegloticase) Approval with Cigna in California: Complete Timeline and Documentation Guide

Answer Box: Renewing Your Krystexxa Coverage

To renew Krystexxa (pegloticase) with Cigna in California: Submit renewal 2-4 weeks before your current authorization expires using Cigna's Krystexxa PA form. Include recent serum uric acid labs showing response (<6 mg/dL), rheumatology progress notes, and documentation of prior allopurinol/febuxostat failures. Standard decisions take up to 15 days; mark "urgent" if delay risks serious health consequences. If denied, file internal appeal within 180 days, then request California DMHC Independent Medical Review for 60-70% chance of overturn.

Renewal Triggers: When to Start
Evidence Update: What Cigna Needs to See
Renewal Packet: Must-Include Documents
Timeline: Submission to Decision
If Your Authorization Lapses
Annual Changes: What to Re-Verify
Appeals Process in California
Personal Progress Tracker

Renewal Triggers: When to Start

Most Cigna Krystexxa authorizations are approved through the end of the calendar year (December 31st) or for specific periods like 6-12 months. Here's when to begin your renewal process:

Start Renewal 2-4 Weeks Early

Check your current authorization expiration date by calling the member services number on your Cigna card
Submit renewal requests 30 days before expiration to avoid treatment gaps
Mark requests "urgent" if you're within 2 weeks of expiration and interruption would cause serious health risks

Note: Many Cigna plans tie specialty drug approvals to the plan year end, requiring annual renewal regardless of when treatment started.

Red Flags That Signal Early Renewal Needed

Your serum uric acid levels have been variable or trending upward
You've had recent infusion reactions or side effects
Your insurance plan is changing for the new year
Your rheumatologist is retiring or you're switching providers

Evidence Update: What Cigna Needs to See

Cigna's Krystexxa coverage policy requires specific evidence that you're still responding to treatment and meeting safety requirements.

Required Lab Documentation

Serum Uric Acid Monitoring:

At least one recent value <6 mg/dL while on Krystexxa
Pre-infusion levels from your last 2-3 treatments
If levels are variable, include physician interpretation

Safety Labs:

G6PD status (one-time, but good to restate)
Basic metabolic panel if clinically indicated

Clinical Response Documentation

Your rheumatologist's progress note should document:

Symptom improvement: Fewer gout flares, reduced joint pain, improved function
Physical findings: Tophus shrinkage or stabilization
Adherence: Confirmation you're receiving 8mg IV every 2 weeks as prescribed
Safety profile: Any infusion reactions and how they're managed

Tip: Request a summary letter from your rheumatologist specifically for insurance renewal that highlights your positive response to Krystexxa.

Renewal Packet: Must-Include Documents

Core Requirements

Document	What to Include	Source
Cigna Krystexxa PA Form	Check "currently receiving" and response questions	Cigna Provider Portal
Progress Note	Within 1-3 months, documenting ongoing response	Rheumatology office
Lab Results	Recent serum uric acid <6 mg/dL	Lab/clinic
Infusion Records	Dates and dosing confirmation	Infusion center

Supporting Documentation

Prior therapy history: Brief restatement of failed allopurinol and febuxostat trials
Concurrent medications: Confirmation no other urate-lowering drugs are being used
Safety monitoring: Documentation of infusion reaction management if applicable

Medical Necessity Letter Checklist

If your rheumatologist writes a supporting letter, ensure it includes:

Diagnosis of chronic refractory gout with tophi or joint damage
Objective response to Krystexxa (lab values, symptom improvement)
Risks of stopping therapy (rebound flares, tophus growth)
Plan for continued monitoring and safety management

Timeline: Submission to Decision

Standard Review Process

Submit: 2-4 weeks before current authorization expires
Cigna decision: Up to 15 calendar days from receipt
Notification: By phone, portal, or mail
Appeals deadline: 180 days from denial date

Expedited Review

Mark your request "urgent" on the PA form if delay would seriously jeopardize your health. Cigna must decide within 72 hours for urgent requests.

When to request expedited review:

Current authorization expires within days
Recent improvement that could reverse quickly
History of severe rebound flares when Krystexxa is interrupted

From our advocates: "One patient whose Krystexxa renewal was delayed by missing labs saw their serum uric acid jump from 2.1 to 8.3 mg/dL in just three weeks, triggering severe flares. Always submit renewals early and keep recent lab results readily available."

If Your Authorization Lapses

Unlike some oral medications, Krystexxa has no automatic bridge or temporary supply program through Cigna. If your authorization expires:

Immediate Steps

Call Cigna member services to confirm PA status and expedite any pending renewal
Contact Accredo (Cigna's specialty pharmacy) to report the lapse
Submit urgent renewal with clinical justification for expedited processing
Discuss interim management with your rheumatologist

Clinical Bridge Considerations

While waiting for renewal approval, your rheumatologist may consider:

Adjusting oral urate-lowering therapy if tolerated
Intensifying anti-inflammatory prophylaxis
Monitoring for rebound hyperuricemia and flares

Note: These are clinical decisions that must be individualized by your treating physician.

Escalation Options

Internal appeal if renewal is denied
Peer-to-peer review with Cigna medical director
California DMHC Independent Medical Review if internal appeals fail

Annual Changes: What to Re-Verify

Cigna can make formulary and coverage changes annually. Before each plan year:

Verify Coverage Status

Check if Krystexxa remains on formulary for your specific plan
Confirm tier placement and any new restrictions
Review PA requirements for changes in step therapy or co-therapy requirements

Review Plan Documents

2025 Prescription Drug List Changes - Check if Krystexxa moved tiers or has new restrictions
Evidence of Coverage - Verify appeals rights and timelines
Provider network - Confirm your rheumatologist and infusion center remain in-network

Methotrexate Co-Therapy Updates

Some payers now require methotrexate co-therapy based on 2022 FDA label updates showing improved response rates. Verify if Cigna has added this requirement to their criteria.

Appeals Process in California

California offers robust appeal rights through both internal insurance company processes and state-level Independent Medical Review.

Internal Appeals with Cigna

First Level:

Deadline: 180 days from denial
Timeline: Up to 30 days for standard, 72 hours for expedited
Submit to: Cigna appeals department (address on denial letter)

Second Level:

Available if first-level appeal is denied
Same timelines and submission process

California DMHC Independent Medical Review

If Cigna upholds the denial after internal appeals, California residents can request Independent Medical Review through the Department of Managed Health Care.

IMR Success Rate: 60-70% overturn rate for specialty drug denials when well-documented

How to File:

Online: DMHC IMR Portal
Phone: 1-888-466-2219
Timeline: 45 days standard, 7 days expedited
Cost: Free to patients

Required Documentation:

All denial letters from Cigna
Complete medical records
Physician letter supporting medical necessity
Evidence of prior therapy failures

Counterforce Health helps patients navigate complex prior authorization and appeals processes by analyzing denial letters, plan policies, and clinical notes to draft targeted, evidence-backed appeals. Their platform identifies specific denial reasons and creates point-by-point rebuttals aligned to each payer's own rules, significantly improving approval rates for specialty medications like Krystexxa.

Personal Progress Tracker

Use this checklist to stay organized throughout the renewal process:

Pre-Renewal Checklist

Current authorization expiration date: ___________
Recent serum uric acid results: ___________
Last rheumatology appointment: ___________
Infusion center contact: ___________
Cigna member services: ___________

Documentation Gathered

Completed Cigna Krystexxa PA form
Recent progress note from rheumatologist
Serum uric acid labs (last 2-3 values)
Infusion dates and dosing records
Prior therapy failure documentation

Submission Tracking

Submission date: ___________
Submission method: ___________
Confirmation number: ___________
Expected decision date: ___________
Follow-up call scheduled: ___________

Decision and Next Steps

Decision received: ___________
Approved/Denied: ___________
New authorization period: ___________
Appeal filed (if needed): ___________

FAQ

How long does Cigna take to decide Krystexxa renewals in California? Standard decisions take up to 15 calendar days. Urgent requests are decided within 72 hours when delay would seriously jeopardize health.

What if my serum uric acid has risen above 6 mg/dL? This typically signals loss of response and increased infusion reaction risk. Cigna may deny renewal, requiring transition back to oral therapy. Document any clinical reasons for the elevation.

Can I request expedited review for my renewal? Yes, mark "urgent" on the PA form if delay would seriously jeopardize your health. Include a physician statement explaining the medical risks of interruption.

Does step therapy apply to Krystexxa renewals? Generally no, if you've already established prior therapy failures. However, Cigna may require documentation that those failures remain relevant and no new options exist.

What if Cigna changes their Krystexxa policy mid-year? Members typically receive 30-day notice of formulary changes. You may be entitled to a transition fill while pursuing an exception or appeal.

Is methotrexate co-therapy required for Krystexxa renewal? This varies by plan. Some Cigna policies now require MTX co-therapy unless contraindicated, based on evidence showing improved response rates.

Sources & Further Reading

For additional support with complex prior authorizations and appeals, Counterforce Health provides specialized assistance in turning insurance denials into successful approvals through evidence-based appeals strategies.

Medical Disclaimer: This information is for educational purposes only and does not constitute medical advice. Always consult with your healthcare provider regarding your specific medical condition and treatment options. Insurance coverage decisions are made by individual payers and may vary based on specific plan terms and clinical circumstances.

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