By Counterforce Health Team in Cresemba (isavuconazole) —

The Requirements Checklist to Get Cresemba (Isavuconazole) Covered by Cigna in Texas

Answer Box: Get Cresemba (Isavuconazole) Covered by Cigna in Texas

Cigna requires prior authorization for Cresemba (isavuconazole) with strict clinical criteria. Fastest approval path: Submit complete PA form with confirmed invasive aspergillosis/mucormycosis diagnosis, infectious disease specialist documentation, and prior therapy failure records. First step today: Contact your prescribing physician to gather diagnostic evidence and treatment history. Appeals available if denied—internal appeals within 180 days, external review through Texas IRO within 4 months. Expedited reviews for urgent cases decided within 72 hours.

Table of Contents

  1. Who Should Use This Checklist
  2. Member & Plan Basics
  3. Clinical Criteria Requirements
  4. Coding & Billing Information
  5. Documentation Packet Essentials
  6. Submission Process
  7. Specialty Pharmacy Coordination
  8. Post-Submission Tracking
  9. Common Denial Prevention Tips
  10. Appeals Process in Texas
  11. Printable Checklist

Who Should Use This Checklist

This comprehensive guide is designed for patients, caregivers, and healthcare providers navigating Cigna's prior authorization process for Cresemba (isavuconazole) in Texas. Use this checklist if you're facing:

  • Initial prior authorization requirements for invasive aspergillosis or mucormycosis treatment
  • Cigna denial letters citing medical necessity or step therapy requirements
  • Specialty pharmacy coordination challenges with Express Scripts or Accredo
  • Appeals preparation for internal or external review processes

Expected outcome: Following this checklist increases approval likelihood by ensuring complete documentation and proper submission procedures. Most complete applications receive decisions within 2-5 business days for standard reviews.

Member & Plan Basics

Coverage Verification Requirements

Requirement Details Where to Verify
Active Cigna Coverage Current enrollment status Cigna member portal or member services
Plan Type Commercial, Medicare Advantage, or Medicaid Insurance card or benefits summary
Specialty Drug Coverage Managed through Express Scripts/Accredo Pharmacy benefits section of plan documents
Deductible Status Applied amounts for current year Member portal or EOB statements
Note: Texas residents with ERISA self-funded employer plans follow federal appeals rules, not state IRO processes.

Prior Authorization Status

Cresemba requires prior authorization across all Cigna plans for both oral capsules and IV formulations. Cigna's antifungal policy mandates approval before dispensing through specialty pharmacy networks.

Clinical Criteria Requirements

FDA-Approved Indications Covered by Cigna

Primary Indications (Approved for up to 6 months):

  • Invasive aspergillosis treatment in adults and pediatric patients
  • Invasive mucormycosis treatment in adults and pediatric patients

Age and Weight Requirements:

  • Oral capsules: ≥6 years old and ≥16 kg body weight
  • IV formulation: ≥1 year old (per FDA labeling)

Step Therapy Requirements

Condition First-Line Requirement Documentation Needed
Invasive Aspergillosis Trial of voriconazole (generic) Failure, intolerance, or contraindication records
Invasive Mucormycosis No step therapy required Confirmed diagnosis with specialist consultation
Clinician Corner: Medical necessity letters should explicitly address why voriconazole cannot be used for aspergillosis cases, including specific adverse events, drug interactions, or clinical failure documentation.

Diagnostic Evidence Requirements

Essential Clinical Documentation:

  • Confirmed invasive fungal infection via culture, histopathology, or imaging
  • Relevant ICD-10 codes: B44.0-B44.7 (aspergillosis), B46.x (mucormycosis)
  • Laboratory results supporting diagnosis (galactomannan, beta-D-glucan, PCR)
  • Imaging studies (CT chest, brain MRI) showing characteristic findings

Coding & Billing Information

HCPCS and NDC Codes

Formulation HCPCS J-Code NDC Numbers Billing Notes
IV Injection J1833 (per mg) 0469-0420-01 Medical benefit, outpatient hospital/clinic
Oral Capsules N/A 0469-0520-02, 0469-2860-35 Pharmacy benefit through specialty pharmacy

Revenue Codes for Hospital Billing

  • 0250: General pharmacy
  • 0260: IV therapy
  • 0636: Drugs requiring detailed coding

Documentation Packet Essentials

Complete Prior Authorization Submission

Required Provider Information:

  • Prescriber NPI and DEA numbers
  • Infectious disease specialist consultation notes (strongly recommended)
  • Contact information for peer-to-peer review requests

Patient-Specific Documentation:

  • Insurance member ID and demographic information
  • Complete medical history relevant to fungal infection
  • Current weight and age (for dosing verification)
  • Allergy and contraindication list

Medical Necessity Letter Components

Your physician's letter should include:

  1. Patient identification and confirmed diagnosis
  2. Clinical evidence supporting invasive aspergillosis or mucormycosis
  3. Prior therapy history with specific dates, dosages, and outcomes
  4. Rationale for Cresemba over alternatives (safety, efficacy, tolerability)
  5. Treatment plan including duration and monitoring approach
  6. Risk statement regarding delayed therapy consequences
From our advocates: Successful appeals often include detailed timelines of prior treatments. One case involved a patient whose voriconazole trial was documented with specific dates, adverse events, and hepatic enzyme elevations—this comprehensive record helped overturn the initial denial within the standard review period.

Submission Process

Preferred Methods:

  1. CoverMyMeds portal - fastest processing
  2. Express Scripts provider portal for Cigna members
  3. Cigna provider services online system

Fax Submission Alternative:

  • Use plan-specific prior authorization forms
  • Include all supporting documentation in single transmission
  • Confirm receipt within 24 hours

Timeline Expectations

Review Type Decision Timeline When Available
Standard Review 2-5 business days Routine cases
Expedited Review 72 hours Urgent medical situations
Peer-to-Peer 1-2 business days After initial denial

Specialty Pharmacy Coordination

Accredo Specialty Pharmacy Process

Pre-Authorization Steps:

  1. Benefits investigation and coverage verification
  2. Patient enrollment and financial assistance screening
  3. Prescription processing upon PA approval
  4. Coordination with prescriber for shipment scheduling

Required Patient Information for Accredo:

  • Complete insurance information and prior authorization number
  • Shipping address and preferred delivery schedule
  • Emergency contact information
  • Storage and handling acknowledgment

Post-Submission Tracking

Status Monitoring Schedule

Day 1-2: Confirmation of receipt from Cigna or Express Scripts Day 3-5: Initial determination for standard reviews Day 6-7: Follow-up if no decision received Day 8+: Escalate to peer-to-peer review if appropriate

Record Keeping Requirements:

  • Confirmation numbers for all submissions
  • Date and time stamps for phone calls
  • Names of representatives contacted
  • Reference numbers for appeals or reviews

Common Denial Prevention Tips

Five Critical Pitfalls to Avoid

  1. Incomplete diagnostic documentation - Always include culture results, pathology reports, or imaging studies confirming invasive infection
  2. Missing step therapy records - For aspergillosis, document specific voriconazole trial dates, dosages, and reasons for discontinuation
  3. Insufficient specialist involvement - Infectious disease consultation strengthens medical necessity arguments significantly
  4. Incorrect coding - Verify current ICD-10 codes and ensure alignment with covered indications
  5. Rushed submissions - Allow time for complete documentation gathering rather than submitting partial applications

Documentation Quality Checklist

  • All required fields completed on PA form
  • Legible provider signatures and dates
  • Complete medical records attached
  • Current laboratory and imaging results included
  • Prior therapy timeline with specific details
  • Clear medical necessity justification

Appeals Process in Texas

Internal Appeals with Cigna

Filing Requirements:

  • Deadline: 180 days from denial date
  • Standard timeline: 30 days for pre-service, 60 days for post-service
  • Expedited timeline: 72 hours for urgent cases

Required Documentation:

  • Original denial letter
  • Additional clinical evidence supporting medical necessity
  • Updated physician letter addressing denial reasons
  • Patient authorization for appeal filing

Texas External Review (IRO)

When Available:

  • After exhausting internal appeals
  • Immediate filing for urgent/life-threatening situations
  • Ongoing specialty therapy interruption cases

Timeline and Process:

  • Standard review: 20 calendar days
  • Expedited review: 3 calendar days (72 hours)
  • Filing deadline: 4 months from final internal denial

Required Forms:

  • Texas Department of Insurance Form LHL712 (verify current form)
  • Signed medical release authorization
  • Complete clinical records supporting appeal
  • Final internal denial letter (unless bypassing for urgent care)
Texas-Specific Rights: State law requires Cigna to comply with IRO decisions that overturn denials. The external review is binding and paid for by the insurer.

For assistance with appeals, contact:

  • Texas Department of Insurance: 1-800-252-3439
  • Office of Public Insurance Counsel: 1-877-611-6742
  • IRO Information Line: 1-866-554-4926

Printable Checklist

Pre-Submission Checklist

Member Information:

  • Active Cigna coverage verified
  • Member ID and demographic information complete
  • Specialty pharmacy benefits confirmed

Clinical Documentation:

  • Confirmed invasive aspergillosis or mucormycosis diagnosis
  • Appropriate ICD-10 codes identified
  • Laboratory/imaging results supporting diagnosis
  • Prior therapy records with dates and outcomes
  • Current weight and age documented

Provider Requirements:

  • Prescriber NPI/DEA numbers included
  • Infectious disease specialist consultation obtained
  • Medical necessity letter completed
  • Contact information for peer-to-peer review

Submission Process:

  • Complete PA form with all required fields
  • Electronic submission via preferred portal
  • Confirmation number obtained and recorded
  • Follow-up schedule established

Post-Submission:

  • Status checked within 2-3 business days
  • Appeal strategy prepared if needed
  • Specialty pharmacy coordination initiated upon approval

Counterforce Health specializes in transforming insurance denials into successful appeals through evidence-based advocacy. Our platform helps patients, clinicians, and specialty pharmacies navigate complex prior authorization requirements by identifying denial reasons and drafting targeted appeals that align with payer-specific criteria. For comprehensive support with Cigna denials and appeals, visit www.counterforcehealth.org.

Sources & Further Reading

Disclaimer: This guide provides general information about insurance coverage processes and should not be considered medical advice. Always consult with your healthcare provider regarding treatment decisions and work with your insurance company directly for plan-specific requirements. Coverage policies and procedures may change; verify current information with official sources.

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