By Counterforce Health Team in Evrysdi (risdiplam) —

Work With Your Doctor to Get Evrysdi (risdiplam) Covered by Cigna in North Carolina: Complete Appeals Guide

Answer Box: Getting Evrysdi (risdiplam) Covered by Cigna in North Carolina

Eligibility: Patients with genetically confirmed spinal muscular atrophy (SMA) can get Evrysdi covered by Cigna with proper documentation. Fastest path: Your doctor submits a prior authorization with genetic test results showing SMN1 mutations, motor function assessments (CHOP INTEND or HFMSE), and clinical notes. If denied, appeal through Cigna's internal process, then file for North Carolina's Smart NC external review within 120 days. Start today: Contact your neurologist to request genetic test copies and schedule a motor function evaluation if not done recently.

Table of Contents

  1. Set Your Goal: Understanding Cigna's Evrysdi Requirements
  2. Visit Prep: Gathering Your Medical History
  3. Building Your Evidence Kit
  4. Medical Necessity Letter Structure
  5. Supporting Your Provider Through Peer-to-Peer Reviews
  6. After-Visit Documentation
  7. Appeals Process for North Carolina
  8. When Respectful Persistence Pays Off
  9. FAQ

Set Your Goal: Understanding Cigna's Evrysdi Requirements

Getting Evrysdi (risdiplam) approved by Cigna requires meeting specific clinical criteria. Your partnership with your healthcare provider is essential—they'll handle the medical documentation while you ensure all necessary records are available.

Coverage Requirements at a Glance

Requirement What It Means Where to Find It Timeline
Prior Authorization Required before dispensing Cigna PA form 72 hours standard
Genetic Testing SMN1 bi-allelic mutations confirmed CLIA-certified lab results Before PA submission
Motor Assessment CHOP INTEND or HFMSE scores Neurology clinic notes Baseline required
Specialty Pharmacy Dispensed through Accredo Provider enrollment needed After PA approval

Key insight: Cigna processes Evrysdi through their specialty pharmacy network, which means your provider must work with Accredo for fulfillment once approved.

Visit Prep: Gathering Your Medical History

Before your appointment, compile a comprehensive timeline to help your provider build the strongest case possible.

Essential Information to Prepare

Symptom Timeline

  • When SMA symptoms first appeared
  • Specific milestones affected (sitting, walking, breathing)
  • Current functional abilities and limitations
  • Recent changes in strength or mobility

Previous Treatments

  • List all SMA medications tried (Spinraza, Zolgensma)
  • Reasons for discontinuation or switching
  • Response to each therapy (improvements, stability, decline)
  • Any adverse reactions or tolerability issues

Current Health Status

  • Weight and height (crucial for Evrysdi dosing)
  • Respiratory function if applicable
  • Swallowing ability and nutritional status
  • Recent hospitalizations or complications
Tip: Create a simple timeline document with dates, treatments, and outcomes. This helps your provider write a more compelling medical necessity letter.

Building Your Evidence Kit

Your provider needs specific documentation to meet Cigna's requirements. Help them gather:

Required Clinical Documentation

Genetic Testing Results

  • Copy of genetic test showing SMN1 mutations
  • Laboratory certification (CLIA-approved facility)
  • Date of testing and methodology used

Motor Function Assessments

  • CHOP INTEND scores for infants/severely affected patients
  • HFMSE scores for ambulatory or sitting patients
  • Baseline measurements before treatment initiation
  • Follow-up assessments if switching therapies

Supporting Medical Records

  • Neurology consultation notes
  • Physical therapy evaluations
  • Pulmonary function tests if relevant
  • Growth charts and nutritional assessments

Counterforce Health specializes in helping patients and providers compile exactly this type of evidence-backed documentation for insurance appeals, turning denials into targeted rebuttals that address payer-specific requirements.

Medical Necessity Letter Structure

Your provider's medical necessity letter is the cornerstone of your prior authorization. Here's what it should include:

Essential Components

Patient Information Section

  • Full diagnosis with ICD-10 codes (G12.0-G12.9)
  • Genetic confirmation details
  • Current weight for dosing calculations
  • SMA type classification

Clinical Rationale

  • Why Evrysdi is medically necessary
  • Previous treatment history and outcomes
  • Contraindications to alternative therapies
  • Expected treatment goals and monitoring plan

Regulatory Compliance

  • Confirmation of FDA labeling criteria
  • Reproductive counseling documentation (if applicable)
  • No concurrent SMN-modifying therapies
  • Prescriber qualifications and experience
Note: The letter should reference peer-reviewed studies like the SUNFISH and FIREFISH trials that demonstrate Evrysdi's efficacy in SMA patients.

Supporting Your Provider Through Peer-to-Peer Reviews

If Cigna requests a peer-to-peer review, your provider will discuss your case directly with a Cigna medical director. You can support this process:

How to Help Your Provider Prepare

Offer Scheduling Flexibility

  • Provide your availability for urgent decisions
  • Understand that peer-to-peer calls often happen within 24-48 hours
  • Be prepared for expedited timelines if clinically urgent

Prepare a Case Summary

  • One-page overview of your SMA history
  • Key clinical markers and functional changes
  • Treatment goals and family preferences
  • Any quality-of-life impacts from delays

Gather Supporting Literature

  • Recent SMA treatment guidelines
  • Relevant case studies or clinical data
  • Insurance policy language supporting coverage
  • State regulations favoring patient access

After-Visit Documentation

After your provider submits the prior authorization, stay organized and proactive:

What to Save and Track

Documentation to Keep

  • Copy of the PA submission
  • Confirmation numbers and submission dates
  • All supporting medical records provided
  • Contact information for follow-up

Portal Communication

  • Save all messages between you and your provider
  • Screenshot any status updates from Cigna
  • Document phone calls with dates and representatives
  • Keep copies of any additional information requests

Appeals Process for North Carolina

If Cigna denies your Evrysdi prior authorization, North Carolina offers strong consumer protections through the Smart NC program.

Internal Appeals with Cigna

Timeline and Process

  • Standard appeals: 15-30 days for review
  • Expedited appeals: 72 hours if urgent
  • Required: Written appeal explaining medical necessity
  • Deadline: Generally 180 days from denial notice

North Carolina External Review

If Cigna's internal appeals are unsuccessful, you can request external review through Smart NC:

Eligibility Requirements

  • Must exhaust Cigna's internal appeals first
  • Applies to state-regulated plans (not self-funded ERISA plans)
  • Denial must be based on medical necessity
  • Must file within 120 days of final denial

Smart NC Process

  • Contact: 1-855-408-1212 for assistance
  • Timeline: 45 days for standard review, 72 hours for expedited
  • Decision: Binding on Cigna if approved
  • Implementation: Coverage within 3 business days if overturned
From our advocates: We've seen numerous specialty drug denials overturned through North Carolina's external review process when patients provide comprehensive clinical documentation and clearly demonstrate failed standard therapies. The key is thorough preparation and understanding that Smart NC reviewers look for evidence-based medical necessity, not just physician preference.

When Respectful Persistence Pays Off

Navigating insurance approvals requires patience and strategic follow-up:

Effective Follow-Up Strategies

Appropriate Cadence

  • Weekly check-ins during active review periods
  • Bi-weekly follow-up during appeals processes
  • Document all communications for your records
  • Use patient portal messaging when possible

Professional Escalation

  • Start with customer service representatives
  • Request supervisor review for complex cases
  • Ask for case manager assignment if available
  • Know when to involve state regulators

Building Relationships

  • Be courteous with all insurance representatives
  • Keep detailed notes of helpful contacts
  • Acknowledge when staff provide good service
  • Maintain professional tone even when frustrated

Companies like Counterforce Health understand that persistence combined with proper documentation often leads to successful outcomes, especially when appeals are backed by evidence that directly addresses the insurer's specific denial reasons.

FAQ

How long does Cigna prior authorization take for Evrysdi in North Carolina? Standard reviews are completed within 72 hours of receiving all required documentation. Expedited reviews for urgent cases are processed within 24 hours.

What if Evrysdi is not on Cigna's formulary? You can request a formulary exception with clinical justification. Your provider must demonstrate medical necessity and why formulary alternatives are inappropriate.

Can I request an expedited appeal if denied? Yes, if delays would seriously jeopardize your health or ability to regain function. Both Cigna and Smart NC offer expedited review processes.

Does step therapy apply to Evrysdi coverage? Cigna may require trial of other SMA treatments first, but exceptions are possible with documentation of contraindications, previous failures, or intolerance.

What happens if Smart NC denies my external review? Smart NC's decision is generally final for administrative appeals. Legal options may remain available, particularly for federal plans not covered by state law.

How much does Evrysdi cost without insurance? List pricing can reach approximately $340,000 annually, with actual costs varying by weight and dosing. Manufacturer patient assistance programs may be available.

Can I appeal while continuing current SMA treatment? Yes, continue current treatments during appeals. Discuss bridge therapy options with your provider if switching from another SMA medication.

What if my employer plan is self-funded? Self-funded ERISA plans don't qualify for North Carolina external review. Use Cigna's internal process, then consider federal legal options if necessary.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical advice. Always consult with your healthcare provider and insurance company for guidance specific to your situation. Insurance policies and state regulations may change; verify current requirements with official sources.

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