By Counterforce Health Team in Crysvita (burosumab) —

The Complete Checklist to Get Crysvita (Burosumab) Covered by Cigna in California: Forms, Appeals, and Requirements

Answer Box: Fastest Path to Approval

Getting Crysvita (burosumab) covered by Cigna in California requires prior authorization through Express Scripts/Accredo with specific documentation: confirmed XLH diagnosis (PHEX gene mutation or elevated FGF23), baseline low serum phosphorus, endocrinologist prescription, and failed oral phosphate therapy. First step today: Have your specialist complete Cigna's current PA form with genetic testing results and clinical notes. Standard approval takes 72 hours; denials can be appealed internally then through California's IMR system with 55% overturn rates.

Table of Contents

  1. Who Should Use This Guide
  2. Member & Plan Basics
  3. Clinical Criteria Checklist
  4. Coding & Billing Requirements
  5. Documentation Packet
  6. Submission Process
  7. Express Scripts/Accredo Enrollment
  8. After Submission: What to Expect
  9. Appeals Process in California
  10. Common Denial Prevention Tips
  11. Printable Requirements Checklist

Who Should Use This Guide

This comprehensive checklist is designed for California patients with X-linked hypophosphatemia (XLH) or tumor-induced osteomalacia (TIO) whose doctors are prescribing Crysvita (burosumab) and need Cigna coverage approval. You'll also find this useful if you've received a denial and need to file an appeal.

Expected outcome: With complete documentation following this checklist, most prior authorization requests are approved within 72 hours. For denials, California's robust appeal system offers favorable outcomes—the state's Independent Medical Review (IMR) process achieves approximately 55% overturn rates for specialty drug medical necessity denials.

Member & Plan Basics

Coverage Requirements

  • Active Cigna coverage in California (commercial, Medicare Advantage, or Medicaid managed care)
  • Specialty drug benefits through Express Scripts/Accredo
  • Prior authorization required for all Crysvita prescriptions

Plan Type Verification

Check your Cigna member portal or ID card to confirm:

  • Formulary tier (typically Tier 5 specialty)
  • Whether step therapy applies
  • Deductible requirements
  • Copay/coinsurance amounts
Tip: Call the member services number on your ID card to verify Crysvita coverage details before starting the PA process.

Clinical Criteria Checklist

Primary Requirements for XLH

✅ Age: Patient ≥6 months old
✅ Diagnosis confirmation (at least one required):

  • PHEX gene mutation in patient or first-degree relative
  • Elevated intact FGF23 (≥30 pg/mL)
  • Positive family history of XLH in first-degree relative

✅ Baseline labs: Fasting serum phosphorus below age-specific normal range (within 90 days)

✅ Specialist prescription: Endocrinologist, nephrologist, or rheumatologist

✅ Clinical evidence:

  • Pediatric: Radiographic rickets, lower extremity bowing
  • Adult: Bone/joint pain limiting activities, osteomalacia

✅ Prior therapy failure: Documented inadequate response or intolerance to oral phosphate plus calcitriol

Exclusion Criteria

❌ No concurrent oral phosphate or active vitamin D therapy
❌ No severe renal impairment or end-stage renal disease
❌ No hypersensitivity to burosumab

Coding & Billing Requirements

Code Type Code Description
HCPCS J-code J0584 Injection, burosumab-twza, 10 mg
ICD-10 (XLH) E83.31 Vitamin D-resistant rickets/osteomalacia
ICD-10 (TIO) M83.0-M83.9 Adult osteomalacia (tumor-induced)
Alternative E83.3 Disorders of phosphorus metabolism

Dosing Information

  • XLH: 0.8 mg/kg every 2 weeks (subcutaneous)
  • TIO: 0.5 mg/kg every 4 weeks (max 2 mg/kg)
  • Weight-based rounding to nearest 10 mg for patients ≥10 kg

Documentation Packet

Medical Necessity Letter Components

Your specialist should include:

  1. Patient demographics and diagnosis with ICD-10 code
  2. Genetic/biochemical confirmation:
    • PHEX mutation results (lab report)
    • FGF23 levels if genetic testing unavailable
    • Family history documentation
  3. Clinical rationale:
    • Baseline fasting serum phosphorus (below normal)
    • Radiographic evidence (X-rays showing rickets/osteomalacia)
    • Symptom documentation (bone pain, growth issues)
  4. Prior treatment history:
    • Oral phosphate and calcitriol therapy details
    • Reasons for discontinuation (ineffective/intolerant)
  5. Treatment plan:
    • Weight-based dosing calculation
    • Administration schedule (every 2-4 weeks)
    • Monitoring plan (serum phosphorus every 4-8 weeks)

Required Attachments

  • Recent lab results (serum phosphorus, FGF23)
  • Genetic testing report
  • Imaging studies (X-rays)
  • Prior therapy documentation
  • Specialist consultation notes
Clinician Corner: Use the Kyowa Kirin Cares downloadable template for XLH cases, which includes all required elements and proper formatting.

Submission Process

Step-by-Step Submission

  1. Obtain current PA form: Download from Cigna's prescription forms page (verify 2024/2025 date)
  2. Complete form sections:
    • Patient demographics and member ID
    • Prescriber information (NPI, specialty)
    • Drug details (NDC, quantity, days supply)
    • Clinical justification
  3. Submit via preferred method:
    • Electronic: Cigna provider portal (fastest processing)
    • Fax: Check current fax number on PA form
    • Phone: For urgent cases requiring expedited review
  4. Mark urgency if applicable: 24-hour review for cases where delay would seriously jeopardize health

Timeline Expectations

  • Standard review: 72 hours with complete documentation
  • Expedited review: 24 hours for urgent cases
  • Incomplete submissions: Additional 72 hours after missing information provided

Express Scripts/Accredo Enrollment

Since Crysvita is a specialty medication, Cigna requires dispensing through Accredo specialty pharmacy (Express Scripts network).

Enrollment Process

  1. Prescriber submits: Complete Accredo Prescription & Enrollment Form via fax to 888.302.1028
  2. Patient registration: Create account at express-scripts.com using member ID
  3. Accredo contact: Patient care representative calls to arrange delivery
  4. Payment setup: Enroll in auto-pay through online portal

Contact Information

  • General Accredo: 855.723.6098 (24/7)
  • Express Scripts Member Services: Number on your ID card
  • Prescription tracking: Accredo mobile app

After Submission: What to Expect

Confirmation & Tracking

  • Record confirmation numbers from all submissions
  • Check status: Cigna provider portal or member services
  • Expected timeline: Initial determination within 72 hours

Possible Outcomes

Outcome Next Steps Timeline
Approved Accredo contacts for delivery scheduling 1-3 business days
Denied Review denial letter; prepare internal appeal Begin within 180 days
More info needed Submit requested documentation 72 hours for new determination

Appeals Process in California

California offers robust patient protections for specialty drug appeals through a two-tier system.

Internal Appeal with Cigna

Timeline: File within 180 days of denial Process:

  1. Submit written appeal with denial letter
  2. Include additional clinical documentation
  3. Request peer-to-peer review if available
  4. Decision: Within 30 days (expedited: 72 hours)

California Independent Medical Review (IMR)

If internal appeal fails, California residents can escalate to the Department of Managed Health Care (DMHC) for external review.

Success rates: 55% overturn rate for medical necessity denials

Process:

  1. File IMR application: Through DMHC website or call 888-466-2219
  2. No fee required: California law prohibits patient charges for IMR
  3. Timeline: 45 days for standard review, 72 hours for expedited
  4. Decision binding: Cigna must comply with IMR determination

Required IMR Documentation

  • Original denial letter
  • Internal appeal decision
  • Complete medical records
  • Specialist letter supporting medical necessity
  • Relevant clinical guidelines and studies

Common Denial Prevention Tips

Five Critical Pitfalls to Avoid

  1. Missing genetic confirmation
    • Fix: Include PHEX mutation results or elevated FGF23 levels
    • Source: Lab report within 90 days
  2. Insufficient baseline labs
    • Fix: Provide fasting serum phosphorus below normal range
    • Timing: Within 90 days of submission
  3. Inadequate prior therapy documentation
    • Fix: Detail oral phosphate + calcitriol trial with outcomes
    • Include: Dosing, duration, reason for discontinuation
  4. Wrong specialist type
    • Fix: Ensure prescription from endocrinologist, nephrologist, or rheumatologist
    • Note: Family medicine/internal medicine typically insufficient
  5. Concurrent contraindicated medications
    • Fix: Discontinue oral phosphate and active vitamin D one week before Crysvita
    • Document: Medication reconciliation in medical necessity letter
From our advocates: We've seen cases where patients were initially denied because their genetic testing was done out-of-state and not properly documented in the current medical record. Always ensure genetic results are clearly referenced in your specialist's letter, even if testing was performed elsewhere. This simple step has helped numerous families avoid unnecessary delays.

Printable Requirements Checklist

Before Submission - Gather These Items:

  • Current Cigna member ID card
  • PHEX gene mutation results OR elevated FGF23 lab
  • Baseline fasting serum phosphorus (below normal)
  • X-rays showing rickets/osteomalacia
  • Prior oral phosphate + calcitriol therapy records
  • Specialist consultation notes (endocrinologist/nephrologist/rheumatologist)
  • Current PA form from Cigna website
  • Patient weight for dosing calculation

Documentation Quality Check:

  • Medical necessity letter includes all 5 required components
  • Lab results dated within 90 days
  • Genetic testing clearly documented in letter
  • Prior therapy failure reasons specified
  • Weight-based dosing calculation included
  • ICD-10 code E83.31 (XLH) or M83.0-M83.9 (TIO)
  • Prescriber NPI and specialty verified

Submission Checklist:

  • PA form completely filled out
  • All attachments included
  • Submitted via provider portal (preferred) or correct fax
  • Confirmation number recorded
  • Follow-up date scheduled (72 hours)

Counterforce Health specializes in turning insurance denials into successful appeals by providing targeted, evidence-backed documentation that aligns with each payer's specific requirements. Our platform helps patients, clinicians, and specialty pharmacies navigate complex prior authorization processes like Cigna's Crysvita coverage requirements, ensuring submissions meet all clinical and procedural standards for faster approvals.

For additional support with Cigna appeals or other insurance challenges, visit www.counterforcehealth.org to learn how our platform can help strengthen your case with payer-specific workflows and comprehensive documentation support.

Frequently Asked Questions

How long does Cigna prior authorization take for Crysvita in California? Standard review takes 72 hours with complete documentation. Expedited review for urgent cases is completed within 24 hours.

What if Crysvita is non-formulary on my Cigna plan? You can request a formulary exception through the prior authorization process. Include clinical justification for why covered alternatives are inappropriate.

Can I appeal if I'm denied for "not medically necessary"? Yes. File an internal appeal with additional clinical evidence, then escalate to California's IMR if needed. Success rates are favorable with proper documentation.

Does step therapy apply if I failed oral phosphate therapy outside California? Yes, prior therapy failures from other states count. Include detailed records of previous treatments and outcomes.

What's the difference between internal appeal and IMR in California? Internal appeals are reviewed by Cigna. IMR is conducted by independent medical experts through California's DMHC and has binding decisions.

How much does Crysvita cost with Cigna coverage? Costs vary by plan. Typical specialty tier copays range from $50-$500+ per month. Check your specific plan benefits and consider manufacturer copay assistance programs.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage decisions vary by individual plan and clinical circumstances. Always consult with your healthcare provider and insurance plan for specific guidance. For assistance with California insurance appeals, contact the DMHC Help Center at 888-466-2219.

Powered by Counterforce Health—AI that turns drug denials into evidence-based appeals patients and clinicians can submit today.