By Counterforce Health Team in Eylea / Lucentis (aflibercept / ranibizumab) —

Work With Your Doctor to Get Eylea and Lucentis Covered by Cigna in North Carolina: Complete Appeals Guide

Answer Box: Getting Eylea/Lucentis Covered by Cigna in North Carolina

Eligibility: Cigna covers Eylea (aflibercept) and Lucentis (ranibizumab) for wet AMD, diabetic macular edema, and other retinal conditions, but requires prior authorization and typically step therapy with bevacizumab first.

Fastest Path: Your ophthalmologist submits a prior authorization through Cigna's provider portal with complete clinical documentation. Approval typically takes 1-5 business days.

First Step Today: Contact your retina specialist's office to confirm they have your complete imaging (OCT, fluorescein angiography), visual acuity measurements, and documentation of any prior anti-VEGF treatments. If denied, North Carolina's Smart NC external review provides binding appeal rights within 120 days.

Table of Contents

  1. Set Your Goal: Understanding Cigna's Requirements
  2. Visit Prep: What to Bring Your Doctor
  3. Evidence Kit: Building Your Clinical Case
  4. Letter of Medical Necessity Structure
  5. Peer-to-Peer Support Strategy
  6. After-Visit Documentation
  7. Respectful Persistence and Appeals
  8. North Carolina External Review Process
  9. FAQ

Set Your Goal: Understanding Cigna's Requirements

Getting Eylea or Lucentis approved by Cigna requires meeting specific clinical criteria and following their step therapy protocol. Here's what you and your doctor need to demonstrate:

Coverage at a Glance

Requirement What It Means Where to Find It
Prior Authorization Required for all anti-VEGF injections Cigna PA Forms
Step Therapy Must try bevacizumab first unless contraindicated Cigna Step Therapy Policy
Diagnosis Documentation OCT, visual acuity, fluorescein angiography Cigna Coverage Policy IP0543
Minimum Dosing Interval Every 28 days (updated 2024) Policy Updates May 2025

Your partnership with your ophthalmologist is crucial because they must provide the clinical evidence Cigna requires. You'll support this process by gathering your treatment history and staying organized throughout the approval journey.

Visit Prep: What to Bring Your Doctor

Before your appointment, create a comprehensive timeline that helps your doctor build the strongest possible case for medical necessity.

Your Symptom and Treatment Timeline

Document these key points:

  • When you first noticed vision changes
  • How symptoms have progressed (better, worse, stable)
  • Impact on daily activities (driving, reading, work)
  • Previous eye treatments and their outcomes
  • Any side effects or intolerances to medications

Treatments You've Tried

Your doctor needs detailed records of:

  • Bevacizumab (Avastin) history: Dates, number of injections, response, side effects
  • Other anti-VEGF treatments: Include brand names, dosing frequency, duration
  • Non-injection treatments: Laser therapy, steroids, supplements
Tip: Bring a written list with dates. This saves appointment time and ensures accuracy in your medical record.

Functional Impact Notes

Cigna evaluates medical necessity partly based on how the condition affects your life. Be specific about:

  • Vision-dependent work requirements
  • Safety concerns (falls, driving)
  • Independence in daily activities
  • Quality of life impact

Evidence Kit: Building Your Clinical Case

Your doctor will compile clinical evidence, but you can help ensure nothing is missed.

Essential Diagnostic Documentation

Required imaging and tests:

  • Optical Coherence Tomography (OCT): Shows retinal thickness and fluid
  • Fluorescein Fundus Angiography (FFA): Demonstrates leakage patterns
  • Visual acuity measurements: Best-corrected vision using standardized charts
  • Fundus photography: Documents retinal changes over time

Published Guidelines Support

Your ophthalmologist should reference current treatment guidelines in the prior authorization. Key sources include:

Medication History Summary

Compile a complete list of:

  • All previous eye medications with dates and outcomes
  • Systemic medications that might affect treatment choice
  • Allergies or contraindications to specific drugs
  • Insurance formulary restrictions you've encountered

Letter of Medical Necessity Structure

Your doctor's letter to Cigna should follow a specific format for maximum impact. Here's what it needs to include:

Essential Components Checklist

Patient Information Section:

  • Full name, date of birth, member ID
  • Diagnosis with ICD-10 codes
  • Relevant medical history

Clinical Rationale:

  • Current visual acuity measurements
  • OCT and FFA findings with dates
  • Disease severity and progression risk
  • Functional impact documentation

Treatment History:

  • Previous anti-VEGF therapies tried
  • Response to treatment or reasons for failure
  • Contraindications to step therapy requirements
  • Timeline of treatment attempts

Medical Necessity Statement:

  • Why the requested medication is appropriate
  • Risks of delaying treatment
  • Expected treatment duration and monitoring plan
  • References to clinical guidelines
Note: Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals by analyzing denial letters and plan policies to create point-by-point rebuttals aligned with payer requirements.

Peer-to-Peer Support Strategy

If Cigna requests a peer-to-peer review, you can help your doctor prepare for this crucial conversation.

Before the Call

Offer your availability windows so your doctor can schedule the review at an optimal time. Provide:

  • Days/times when you're available if the reviewer wants to discuss your case
  • Contact information where you can be reached
  • Any scheduling constraints

Case Summary Preparation

Help your doctor create a concise summary:

  • 30-second elevator pitch: Diagnosis, why standard therapy failed, why this medication is necessary
  • Key supporting data: Most compelling OCT findings, visual acuity trends, functional impact
  • Specific policy references: Quote relevant sections from Cigna's coverage criteria

Documentation Support

Ensure your doctor has immediate access to:

  • All imaging studies with interpretation reports
  • Complete medication trial history with dates and outcomes
  • Any specialist consultations or second opinions
  • Relevant published studies supporting the treatment approach

After-Visit Documentation

Proper documentation after your appointment ensures nothing falls through the cracks.

What to Save

Keep copies of:

  • Prior authorization submission confirmation
  • All supporting clinical documents sent to Cigna
  • Your doctor's notes from the visit
  • Any communication with Cigna or your pharmacy

Portal Messaging Best Practices

When communicating with your doctor's office through patient portals:

  • Be specific: Reference dates, medication names, and Cigna case numbers
  • Include context: Mention previous conversations or submissions
  • Ask clear questions: "Has Cigna responded to the PA submitted on [date]?"
  • Provide updates: Share any direct communication you receive from Cigna

Tracking Your Case

Create a simple log with:

  • Submission date and method
  • Cigna reference numbers
  • Expected decision timeline
  • Follow-up dates and actions needed

Respectful Persistence and Appeals

If your initial prior authorization is denied, don't give up. Cigna has multiple appeal levels, and persistence often pays off.

Internal Appeals Process

First-Level Appeal:

  • Submit within 180 days of denial
  • Include additional clinical documentation
  • Request expedited review if urgent (24-72 hours)

Second-Level Appeal:

  • Available if first appeal is denied
  • May include peer-to-peer review opportunity
  • Timeline: typically 30 days for decision

Escalation Strategy

Week 1-2: Work with your doctor's office to gather any missing documentation Week 3-4: Consider peer-to-peer review if offered Week 5+: Prepare for external review through Smart NC if internal appeals fail

Professional Communication

When following up:

  • Call frequency: No more than twice per week unless urgent
  • Documentation: Keep records of all conversations
  • Tone: Remain professional and focus on medical necessity
  • Escalation path: Ask to speak with supervisors if needed

North Carolina External Review Process

North Carolina offers one of the strongest external review programs in the country through Smart NC.

Timeline and Requirements

Step Timeline Action Required
Apply Within 120 days of final denial Submit Smart NC form
Review 45 days standard, 72 hours urgent Provide additional documentation if requested
Decision Binding on Cigna Coverage must begin within 3 business days if approved

What Smart NC Needs

Required Documentation:

  • Final denial letter from Cigna
  • Medical records supporting treatment necessity
  • Insurance card copy
  • Completed external review request form

Supporting Evidence:

  • All prior authorization submissions
  • Clinical notes and imaging studies
  • Documentation of failed alternative treatments
  • Statement of medical necessity from your doctor

Expedited Reviews

Request expedited review if:

  • Delay could cause serious vision loss
  • Your condition is rapidly progressing
  • Standard timeline poses health risks

Contact Smart NC at 1-855-408-1212 for guidance on expedited requests.

From our advocates: We've seen patients successfully overturn Cigna denials through Smart NC by providing comprehensive documentation of failed bevacizumab trials and clear evidence of disease progression. The key is thorough preparation and meeting all deadlines—Smart NC's decisions are binding and have helped many patients access critical eye treatments when initial appeals failed.

FAQ

How long does Cigna prior authorization take in North Carolina? Standard prior authorization decisions are made within 1-5 business days. Urgent requests are processed within 24-72 hours.

What if Eylea or Lucentis is non-formulary on my plan? You can request a formulary exception with clinical documentation showing medical necessity. Your doctor must demonstrate why formulary alternatives are inappropriate.

Can I request an expedited appeal? Yes, if delay could cause serious harm to your vision. Both Cigna's internal process and Smart NC external review offer expedited timelines.

Does step therapy apply if I tried bevacizumab in another state? Yes, documented trials from other providers count toward step therapy requirements. Ensure your current doctor has complete records.

What happens if Smart NC denies my external review? Smart NC's decision is final for administrative appeals. You may have legal options, but should consult an attorney familiar with ERISA and insurance law.

How much do these medications cost without insurance? Eylea and Lucentis typically cost $1,200-$2,500 per injection. Manufacturer patient assistance programs may be available if insurance coverage is denied.

Can I appeal if my employer plan is self-funded? Self-funded ERISA plans don't qualify for Smart NC external review. You must follow the plan's internal appeal process, then potentially pursue federal court options.

What if I need treatment while appeals are pending? Discuss with your doctor about temporary alternatives or manufacturer compassionate use programs. Don't delay necessary treatment for administrative processes.

When navigating insurance coverage for critical eye treatments, having the right support makes all the difference. Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into successful appeals by analyzing denial letters, plan policies, and clinical notes to create targeted, evidence-backed rebuttals that align with each payer's specific requirements.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Always consult with your healthcare provider about treatment decisions and with qualified professionals about insurance appeals. Coverage policies and requirements may vary by plan and change over time. Verify current requirements with Cigna and applicable North Carolina regulations.

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