By Counterforce Health Team in Oxervate (cenegermin) —

Work With Your Doctor to Get Oxervate (Cenegermin) Approved by Cigna in Michigan: Complete Provider Collaboration Guide

Answer Box: Getting Oxervate (Cenegermin) Approved by Cigna in Michigan

Oxervate requires prior authorization from Cigna with strict documentation requirements. Your ophthalmologist must document stage 2 or 3 neurotrophic keratitis, failed conservative treatments (minimum 14 days preservative-free artificial tears), and corneal sensation testing results. First step today: Schedule an appointment with your eye doctor to review your treatment history and gather required documentation. If denied, Michigan offers external review through DIFS within 127 days of final denial. Cigna PA requirements | Michigan DIFS appeals

Table of Contents

  1. Set Your Goal: What Approval Requires
  2. Visit Prep: Organizing Your Medical History
  3. Evidence Kit: Clinical Documentation
  4. Medical Necessity Letter Structure
  5. Peer-to-Peer Review Support
  6. After-Visit Summary
  7. Respectful Persistence Strategy
  8. Appeals Playbook for Michigan
  9. FAQ

Set Your Goal: What Approval Requires

Getting Oxervate (cenegermin) covered by Cigna requires a collaborative approach with your ophthalmologist. This FDA-approved treatment for neurotrophic keratitis comes with specific coverage criteria that must be met precisely.

Coverage Requirements at a Glance

Requirement What It Means Documentation Needed
Diagnosis Stage 2 or 3 neurotrophic keratitis Corneal exam findings, staging notes
Prescriber Ophthalmologist or optometrist Provider credentials verification
Age Patient must be 2+ years old Medical records
Step Therapy Failed 14+ days artificial tears Treatment timeline, response documentation
Corneal Testing Documented sensation loss Cochet-Bonnet or cotton wisp results
Duration One 8-week course per eye Treatment plan justification

Source: Cigna Oxervate Policy

Your partnership with your doctor is crucial because they must provide detailed clinical evidence supporting medical necessity. Unlike routine medications, Oxervate requires comprehensive documentation of your condition's severity and treatment history.

Visit Prep: Organizing Your Medical History

Before your appointment, gather information that will help your ophthalmologist build a strong case for coverage. This preparation can make the difference between approval and denial.

Create Your Treatment Timeline

Document every eye treatment you've tried, including:

  • Artificial tears and lubricants: Brand names, frequency, duration of use, and response
  • Therapeutic contact lenses: Type, dates worn, outcomes
  • Surgical interventions: Tarsorrhaphy, amniotic membrane grafts, dates and results
  • Other treatments: Punctal plugs, autologous serum tears, topical medications

Symptom Impact Notes

Write down how your condition affects daily activities:

  • Vision changes and when they occur
  • Pain levels and triggers
  • Work or school limitations
  • Sleep disruptions from eye discomfort

Insurance Information to Bring

  • Current Cigna insurance card
  • Policy number and group information
  • Previous denial letters (if any)
  • Explanation of Benefits (EOB) statements
Tip: Use your phone to take photos of your eye symptoms between appointments. Visual documentation can strengthen your case, though professional slit-lamp photos from your doctor carry more weight.

Evidence Kit: Clinical Documentation

Your ophthalmologist needs specific clinical evidence to support the prior authorization request. Understanding what's required helps you advocate for thorough documentation during your visit.

Essential Clinical Tests

Corneal Sensation Testing

  • Must be performed before any eye drops are instilled
  • Cochet-Bonnet esthesiometer provides quantitative results
  • Cotton wisp testing offers qualitative assessment
  • Results must be documented in clinical notes

Slit-Lamp Examination

  • Detailed description of epithelial defects
  • Stromal involvement assessment
  • Corneal staining patterns with fluorescein
  • Photographic documentation when possible

Staging Documentation Your doctor must clearly identify your condition as stage 2 or 3:

  • Stage 2: Persistent epithelial defect with stromal involvement
  • Stage 3: Corneal ulceration with stromal melting or thinning risk

Treatment Failure Documentation

Cigna requires proof that conservative treatments haven't worked:

  1. Preservative-free artificial tears: Minimum 14 consecutive days
  2. Additional supportive measures: Therapeutic contact lenses, punctal occlusion
  3. Response assessment: Objective measurements of healing progress
  4. Contraindications: Why other treatments weren't appropriate

Medical Necessity Letter Structure

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

Key Components Checklist

Patient Information

  • Full name, date of birth, Cigna member ID
  • Diagnosis with ICD-10 code (H16.239 for neurotrophic keratitis)
  • Clear staging (stage 2 or 3) with clinical justification

Clinical Rationale

  • Detailed symptom history and progression
  • Objective examination findings
  • Corneal sensation test results with methodology
  • Risk assessment without treatment

Treatment History

  • Chronological list of all prior therapies
  • Duration and dosing of each treatment
  • Objective response measurements
  • Reasons for discontinuation or failure

Medical Necessity Statement

  • Why Oxervate is specifically needed
  • Risk of vision loss without treatment
  • FDA approval and clinical evidence references
  • Treatment plan (1 drop 6 times daily for 8 weeks)
From our advocates: We've seen cases where adding a simple timeline table to the medical necessity letter—showing dates, treatments tried, and outcomes—significantly improved approval rates. The visual format helps reviewers quickly understand the progression and treatment failures.

Supporting Literature

Your doctor should reference:

  • FDA approval documentation
  • Clinical trial data showing 70% healing rates vs. 28% with placebo
  • American Academy of Ophthalmology treatment guidelines

Peer-to-Peer Review Support

If Cigna initially questions the prior authorization, your ophthalmologist can request a peer-to-peer review with Cigna's medical director. This conversation often resolves coverage issues quickly.

How to Support Your Doctor

Provide Availability Windows

  • Offer to coordinate scheduling between your doctor's office and Cigna
  • Be flexible with timing to accommodate both parties

Prepare a Case Summary Create a one-page summary including:

  • Your diagnosis and staging
  • Complete treatment history with dates
  • Current symptoms and functional impact
  • Urgency factors (risk of perforation, vision loss)

What Happens During Peer-to-Peer

Your ophthalmologist will discuss your case directly with Cigna's reviewing physician, explaining:

  • Clinical findings that support the diagnosis
  • Why previous treatments failed
  • Medical necessity for Oxervate specifically
  • Risks of delaying treatment

This professional-to-professional conversation often carries more weight than written documentation alone.

After-Visit Summary

After your appointment, ensure all necessary steps are completed and documented properly.

Documents to Request

  • Copy of your complete medical record from the visit
  • Clinical photographs or imaging (if taken)
  • Laboratory results or diagnostic test reports
  • Treatment plan documentation
  • Prior authorization submission confirmation

Portal Communication

Use your patient portal effectively:

  • Send follow-up questions about timeline expectations
  • Request copies of submitted forms
  • Ask for updates on authorization status
  • Clarify next steps if initial submission is incomplete

What to Save

Maintain organized records of:

  • All correspondence with Cigna
  • Provider office communications
  • Submission confirmation numbers
  • Response letters and timelines

Respectful Persistence Strategy

Insurance approvals often require follow-up. Here's how to stay engaged without overwhelming your healthcare team.

Follow-Up Cadence

Week 1-2: Allow time for initial review Week 3: Gentle inquiry about status Week 4+: More frequent contact if no response

Escalation Protocol

  1. Start with office staff: They handle most insurance communications
  2. Request nurse involvement: For clinical questions or clarifications
  3. Ask to speak with doctor: If medical necessity is questioned
  4. Consider patient advocate: For complex cases or repeated denials

Communication Scripts

For office staff: "I wanted to check on the status of my Oxervate prior authorization submitted on [date]. Is there anything I can do to help move the process along?"

For insurance follow-up: "I'm calling to check on prior authorization request #[number] for Oxervate. My doctor submitted this on [date] for my neurotrophic keratitis treatment."

Appeals Playbook for Michigan

If Cigna denies your initial request, Michigan offers robust appeal rights through multiple levels of review.

Internal Appeals Process

First Level Internal Appeal

  • File within 180 days of denial
  • Submit through Cigna member portal or mail
  • Include all supporting documentation
  • Standard review: 15 calendar days
  • Expedited review: 72 hours (if urgent)

Second Level Internal Appeal

  • Available if first appeal is denied
  • Same timeline and submission requirements
  • Different medical reviewers examine the case

Michigan External Review

After exhausting internal appeals, you can request external review through the Michigan Department of Insurance and Financial Services (DIFS).

Timeline: File within 127 days of final internal denial Process: DIFS assigns Independent Review Organization (IRO) Decision timeframe: 60 days maximum (often faster) Expedited option: 72 hours with physician letter stating urgency

How to File

Note: Michigan's 127-day deadline is longer than the federal 120-day standard, giving you extra time to prepare your external appeal.

Required Documentation for Appeals

  • Complete denial letter from Cigna
  • All medical records related to your condition
  • Your ophthalmologist's supporting letter
  • Treatment history timeline
  • Any additional clinical evidence

Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals by analyzing denial letters, plan policies, and clinical notes to draft point-by-point rebuttals aligned with payer requirements. Their platform helps patients, clinicians, and specialty pharmacies navigate complex prior authorization processes for medications like Oxervate. Learn more about their services.

FAQ

How long does Cigna prior authorization take for Oxervate in Michigan? Standard review takes up to 15 calendar days. Expedited review (for urgent cases) takes 72 hours. Your doctor must request expedited review with clinical justification.

What if Oxervate isn't on Cigna's formulary? You can request a formulary exception through Cigna's coverage determination process. Your doctor must demonstrate medical necessity and why formulary alternatives aren't appropriate.

Can I appeal if I live in Michigan but have coverage from another state? Yes, Michigan residents can use DIFS external review regardless of where their insurance plan originates, as long as they receive care in Michigan.

Does step therapy apply if I tried treatments in another state? Yes, properly documented treatment failures from any location should satisfy step therapy requirements. Ensure your Michigan ophthalmologist has complete records.

How much does Oxervate cost without insurance? An 8-week course typically costs in the low six figures. Dompé offers patient assistance programs that may help with costs during the appeal process.

What counts as "failed conservative treatment" for Cigna? Minimum 14 consecutive days of preservative-free artificial tears, plus documentation of inadequate response. Additional treatments like therapeutic contact lenses strengthen your case.

Can I request a peer-to-peer review before formal denial? Yes, your ophthalmologist can proactively request peer-to-peer discussion during the initial review process, which may prevent denial.

What if my case is urgent due to risk of perforation? Request expedited review immediately. Your doctor must provide written documentation of the urgent medical need. Both Cigna and DIFS offer 72-hour expedited timelines.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical advice. Always consult with your healthcare provider about your specific condition and treatment options. Insurance coverage policies may change, and individual circumstances vary. For the most current information about Michigan insurance appeals, contact DIFS at 877-999-6442.

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