By Counterforce Health Team in Acthar Gel (repository corticotropin injection) —

Work With Your Doctor to Get Acthar Gel Covered by Cigna in North Carolina: Complete Prior Authorization and Appeals Guide

Answer Box

Getting Acthar Gel (repository corticotropin injection) covered by Cigna in North Carolina requires prior authorization approval before dispensing through Express Scripts' Accredo specialty pharmacy. Your fastest path: (1) Verify your diagnosis meets Cigna's approved conditions (infantile spasms, MS exacerbations, rheumatologic disorders), (2) Document corticosteroid failure/intolerance with dates and outcomes, and (3) Submit Cigna's official PA form with complete clinical records. If denied, North Carolina's Smart NC program offers free external review within 120 days. Start today by requesting your complete medical records and scheduling a visit with your specialist to discuss prior treatment failures.

Table of Contents

  1. Set Your Goal: Understanding Cigna's Approval Requirements
  2. Visit Preparation: Building Your Clinical Case
  3. Evidence Kit: Gathering Supporting Documentation
  4. Medical Necessity Letter Structure
  5. Peer-to-Peer Review Support
  6. After-Visit Documentation
  7. Respectful Persistence: Following Up Effectively
  8. Appeals Playbook for North Carolina
  9. FAQ

Set Your Goal: Understanding Cigna's Approval Requirements

Working with your doctor to secure Acthar Gel coverage starts with understanding exactly what Cigna requires. Acthar Gel requires prior authorization for all indications, and Cigna approves multidose vials (not single-dose injectors) for FDA-approved conditions when specific criteria are met.

Coverage at a Glance

Requirement What It Means Where to Find It
Prior Authorization Mandatory approval before dispensing Cigna PA Form
Approved Diagnoses Infantile spasms, MS exacerbations, RA, lupus nephritis, nephrotic syndrome Cigna Coverage Policy
Step Therapy Documented corticosteroid failure/intolerance Medical records, pharmacy history
Specialty Pharmacy Dispensed through Accredo Accredo Referral Form
Review Timeline 5 business days standard Cigna provider portal

Your partnership with your doctor is crucial because Cigna requires comprehensive clinical documentation that only your healthcare provider can provide. This includes your complete treatment history, current symptoms, and medical rationale for why Acthar Gel is necessary when other treatments have failed.

Note: Cigna covers Acthar Gel for one month initially if all criteria are met, with reauthorization requiring documented clinical response.

Visit Preparation: Building Your Clinical Case

Before your appointment, create a detailed timeline that your doctor can use to build a compelling medical necessity case. This preparation makes your visit more efficient and ensures nothing important is missed.

Symptom Timeline Documentation

Create a chronological record of your condition, including:

  • Initial diagnosis date with specific ICD-10 codes (e.g., G40.419 for infantile spasms, G35 for MS)
  • Symptom progression with dates, severity, and functional impact
  • Hospitalizations or emergency visits related to your condition
  • Quality of life impacts on work, family, and daily activities

Treatment History Compilation

Document every medication trial with specific details:

  • Corticosteroid trials: Exact medications (prednisone, methylprednisolone, dexamethasone), doses, duration, and outcomes
  • Failure reasons: Lack of efficacy, intolerable side effects, or contraindications
  • Other therapies tried: Include immunosuppressants, DMARDs, or condition-specific treatments
  • Dates and prescribing physicians for each trial
Tip: Request pharmacy records from your insurance company or pharmacy to ensure you have complete documentation of all previous medications.

Functional Impact Notes

Prepare specific examples of how your condition affects your daily life:

  • Work limitations: Missed days, reduced productivity, accommodation needs
  • Family impact: Caregiving requirements, social limitations
  • Physical symptoms: Pain levels, mobility issues, cognitive effects
  • Emergency situations: Acute flares requiring urgent care

Evidence Kit: Gathering Supporting Documentation

Your doctor will need comprehensive evidence to support the prior authorization request. Gather these documents before your visit to streamline the process.

Essential Clinical Records

Laboratory and imaging results that support your diagnosis:

  • Recent blood work showing disease activity markers
  • Imaging studies (MRI, X-rays) demonstrating disease progression
  • Specialist consultation notes from neurologists, rheumatologists, or nephrologists
  • EEG results for infantile spasms cases

Published Guidelines and Evidence

Help your doctor access relevant clinical literature:

  • FDA labeling for Acthar Gel showing approved indications
  • Specialty society guidelines (American Academy of Neurology, American College of Rheumatology)
  • Peer-reviewed studies supporting Acthar Gel's efficacy in your condition
  • Comparative effectiveness data vs. standard corticosteroids

Insurance Documentation

Organize your insurance information:

  • Current Cigna member ID and policy details
  • Previous denial letters or explanation of benefits (EOB)
  • Formulary tier information for Acthar Gel
  • Any prior authorization forms already submitted
Clinician Corner: The medical necessity letter should include specific ICD-10 codes, detailed treatment history with dates and outcomes, clinical rationale for Acthar Gel vs. alternatives, and references to FDA labeling and clinical guidelines. Include patient weight/BSA for dosing calculations and planned monitoring protocols.

Medical Necessity Letter Structure

The medical necessity letter is the cornerstone of your prior authorization request. Work with your doctor to ensure it includes all required elements in a clear, compelling format.

Letter Template Components

Header Information:

  • Date and patient demographics (name, DOB, Cigna ID)
  • Prescriber credentials, NPI, and contact information
  • Addressed to Cigna Pharmacy Director or Medical Review

Clinical Documentation:

  • Diagnosis: Specific condition with ICD-10 code and supporting test results
  • Treatment History: Detailed corticosteroid trials with doses, durations, and failure reasons
  • Medical Rationale: Why Acthar Gel is medically necessary vs. alternatives
  • Dosing Plan: FDA-approved dosing (e.g., 75-150 U/m² IM for infantile spasms)
  • Monitoring Plan: Safety monitoring and response assessment protocols

Supporting Evidence:

  • References to FDA labeling and clinical guidelines
  • Peer-reviewed studies supporting efficacy
  • Contraindications to alternative therapies
  • Risk of treatment delay
From Our Advocates: We've seen successful appeals when doctors include specific failure details like "prednisone 2 mg/kg/day for 3 weeks resulted in minimal seizure reduction (from 50 to 40 spasms daily) with significant weight gain and mood changes, requiring discontinuation." Concrete details strengthen the medical necessity case.

Peer-to-Peer Review Support

If your initial prior authorization is denied, your doctor can request a peer-to-peer review with Cigna's medical director. This conversation often resolves denials when clinical evidence is compelling.

Preparing Your Doctor for P2P

Offer to help your doctor prepare by providing:

  • Availability windows: When you and your doctor are available for the call
  • Case summary: 1-2 page summary of your condition, treatments tried, and why Acthar Gel is necessary
  • Key talking points: Specific clinical evidence and guideline references
  • Failure documentation: Exact details of corticosteroid trials and outcomes

P2P Discussion Points

Your doctor should be prepared to discuss:

  • Mechanism of action: Acthar Gel's unique immunomodulatory effects via melanocortin receptors
  • Clinical evidence: Condition-specific studies showing efficacy vs. corticosteroids
  • Safety profile: Lower cortisol exposure compared to synthetic ACTH
  • Treatment goals: Specific outcomes expected with Acthar Gel therapy

Counterforce Health specializes in helping patients and providers navigate complex prior authorization requirements and appeals. Their platform can help identify the specific denial reasons and craft targeted rebuttals aligned with Cigna's policies. Visit www.counterforcehealth.org to learn more about their evidence-backed appeal services.

After-Visit Documentation

Save everything from your appointment and maintain organized records for potential appeals.

Essential Documents to Request

  • Copy of the completed prior authorization form
  • Medical necessity letter with your doctor's signature
  • All supporting clinical documentation submitted
  • Confirmation of submission (fax confirmation or portal receipt)
  • Your doctor's notes from the visit

Portal Communication

Use your patient portal effectively:

  • Message your doctor if you remember additional treatment details
  • Request copies of any additional documentation needed
  • Ask for updates on prior authorization status
  • Clarify next steps if approval is delayed

Respectful Persistence: Following Up Effectively

Follow up strategically without overwhelming your healthcare team. Cigna's standard review timeline is 5 business days, but complex cases may take longer.

Follow-Up Schedule

  • Day 3: Check with your doctor's office on submission status
  • Day 7: If no response, ask your doctor to call Cigna for status update
  • Day 10: If denied, discuss appeal options immediately
  • Ongoing: Weekly check-ins during appeals process

Escalation Strategies

When to escalate politely:

  • Prior authorization exceeds 10 business days without response
  • Denial appears to be based on incorrect information
  • Your condition is worsening while waiting for approval
  • Administrative errors are causing delays

Appeals Playbook for North Carolina

If Cigna denies your Acthar Gel prior authorization, North Carolina offers strong consumer protections through internal appeals and external review.

Internal Appeals Process

Level 1 Internal Appeal:

  • Timeline: Submit within 180 days of denial
  • Decision: 30 days for standard, 72 hours for expedited
  • Requirements: Include denial letter, additional clinical evidence, enhanced medical necessity letter

Level 2 Internal Appeal:

  • Timeline: Submit within 60 days of Level 1 denial
  • Decision: 30 days for standard, 72 hours for expedited
  • Enhanced evidence: New clinical studies, specialist consultation, peer-to-peer notes

Smart NC External Review

North Carolina's external review program provides independent review at no cost:

  • Eligibility: State-regulated plans (most individual and group plans)
  • Timeline: Request within 120 days of final internal denial
  • Decision: 45 days standard, 72 hours expedited
  • Contact: Smart NC helpline at 1-855-408-1212

Smart NC provides free advocacy to help you:

  • Complete external review request forms
  • Gather supporting medical records
  • Communicate with Cigna during the process
  • Find additional clinical evidence for your case
Note: Smart NC's decision is binding on Cigna. If they approve coverage, Cigna must provide it within 3 business days.

When to Request Expedited Review

Request expedited appeals if:

  • Delay would seriously jeopardize your life or health
  • Your condition is rapidly worsening
  • You're experiencing frequent hospitalizations
  • Standard timeline would cause irreversible harm

FAQ

How long does Cigna prior authorization take for Acthar Gel in North Carolina? Standard review is 5 business days. Expedited review (when health is at risk) is decided within 72 hours. Complex cases may take longer, requiring follow-up with your doctor.

What if Acthar Gel is non-formulary on my Cigna plan? You can request a formulary exception through the same prior authorization process. Your doctor must demonstrate medical necessity and why formulary alternatives are inappropriate.

Can I appeal if I tried corticosteroids outside North Carolina? Yes, treatment history from any location counts toward step therapy requirements. Ensure your doctor includes complete documentation from all providers.

Does Cigna require a specialist to prescribe Acthar Gel? While not explicitly required, specialist involvement (neurologist for infantile spasms, rheumatologist for autoimmune conditions) strengthens prior authorization requests significantly.

What happens if Smart NC external review is denied? Smart NC's decision is final for the administrative process. You may have legal rights to pursue coverage through other means, but should consult with a healthcare attorney.

Are there patient assistance programs for Acthar Gel? Yes, Acthar Patient Support provides copay assistance and free injection training. Contact 1-888-435-2284 for eligibility and enrollment.

How do I know if my Cigna plan uses Express Scripts/Accredo? Check your member portal or call Cigna member services. Most Cigna plans designate Accredo for specialty medications like Acthar Gel.

Can I get Acthar Gel from a local pharmacy? No, Cigna requires specialty pharmacy dispensing through their designated network, typically Accredo, due to the medication's complexity and cost.

Sources & Further Reading

Disclaimer: This article provides educational information about insurance coverage and is not medical advice. Always consult with your healthcare provider about treatment decisions and work with qualified professionals for insurance appeals. Coverage policies and procedures may change; verify current requirements with Cigna and North Carolina regulators. Counterforce Health offers specialized support for navigating prior authorization denials and appeals, helping patients and providers build evidence-backed cases for coverage approval. Their platform analyzes denial letters and payer policies to create targeted appeals that align with insurer requirements.

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