By Counterforce Health Team in Photrexa (riboflavin ophthalmic solution) —

Work With Your Doctor to Get Photrexa Covered by Cigna in California: Complete Appeals Guide

Answer Box: Getting Photrexa Covered by Cigna in California

Fastest path to approval: Work with your ophthalmologist to submit a prior authorization (PA) request with documented keratoconus progression evidence—specifically Kmax increase ≥1.0 diopter and serial corneal topography. If denied, file an internal appeal within 180 days, then request California's Independent Medical Review (IMR) for a binding external decision.

First step today: Call your eye doctor's office to schedule a visit and request copies of all your corneal topography reports from the past 2 years. Bring your Cigna insurance card and any denial letters you've received.

Table of Contents

  1. Set Your Goal: What Approval Requires
  2. Visit Prep: Building Your Case
  3. Evidence Kit: Clinical Documentation
  4. Letter of Medical Necessity Structure
  5. Peer-to-Peer Review Support
  6. After-Visit Summary
  7. Respectful Persistence
  8. Appeals Playbook for California
  9. Common Denial Reasons & Fixes
  10. FAQ

Set Your Goal: What Approval Requires

Photrexa (riboflavin ophthalmic solution) is used with the iLink system for corneal cross-linking in progressive keratoconus. Cigna requires prior authorization with specific clinical evidence to prove medical necessity.

Coverage Requirements at a Glance

Requirement What it means Where to find it Source
PA needed? Yes, for all Photrexa requests Cigna formulary Cigna PA Forms
Diagnosis codes H18.621 (unstable keratoconus, right) or H18.622 (left) Medical records ICD-10 Documentation
Progression evidence Kmax increase ≥1.0 diopter over 6-12 months Serial topography Clinical Guidelines
Prior treatments Failed contact lens trials or intolerance Clinical notes Cigna PA Form
FDA protocol Epithelium-off cross-linking with iLink system Provider attestation Glaukos Reimbursement

Your partnership with your ophthalmologist is crucial—they'll need to provide the clinical evidence while you help gather documentation and navigate the insurance process.

Visit Prep: Building Your Case

Come to your appointment prepared with a detailed history that supports medical necessity for Photrexa.

Before Your Visit: Gather This Information

Symptom Timeline:

  • When did you first notice vision changes?
  • How has your vision worsened over time?
  • Any specific activities that have become difficult (driving at night, reading, computer work)?

Previous Treatments:

  • Contact lenses tried (brand, type, dates worn)
  • Reasons for discontinuing each lens type
  • Any other treatments attempted
  • Side effects or complications experienced

Functional Impact:

  • How keratoconus affects your daily life
  • Work or school limitations
  • Quality of life changes
Tip: Write down specific examples like "I can no longer drive at night safely" or "I need to hold books 6 inches from my face to read." These details help justify medical necessity.

Questions to Ask Your Doctor

  1. "Do my topography results show progression that meets Cigna's criteria?"
  2. "Can you provide a letter explaining why Photrexa is medically necessary for me?"
  3. "What documentation do we need for the prior authorization?"
  4. "If we're denied, will you participate in a peer-to-peer review with Cigna?"

Evidence Kit: Clinical Documentation

Your ophthalmologist needs specific clinical evidence to support the PA request. Help them compile a complete picture of your condition.

Essential Clinical Documents

Serial Corneal Topography:

  • At least two measurements, 3-6 months apart
  • Clear evidence of Kmax increase ≥1.0 diopter
  • Pachymetry showing corneal thinning
  • Visual documentation of progression patterns

Treatment History:

  • Detailed record of contact lens trials
  • Dates, types, and reasons for failure
  • Any adverse reactions or complications
  • Documentation of functional decline

Laboratory and Imaging:

  • Current corneal thickness measurements
  • Visual acuity testing results
  • Any additional imaging studies
Note: Counterforce Health helps patients and providers compile evidence-backed appeals by identifying the specific documentation requirements for each payer's policies.

Published Guidelines to Reference

Your doctor should reference established clinical guidelines in the medical necessity letter:

  • FDA labeling for Photrexa and iLink system
  • American Academy of Ophthalmology keratoconus guidelines
  • Corneal cross-linking consensus statements

Letter of Medical Necessity Structure

Work with your ophthalmologist to ensure the medical necessity letter includes these key elements:

Required Components

1. Patient and Diagnosis Information

  • Full name, date of birth, Cigna member ID
  • ICD-10 codes: H18.621 or H18.622 (specify eye and progression status)
  • Clear diagnosis of progressive keratoconus

2. Clinical Rationale

  • Objective evidence of progression (Kmax changes, pachymetry)
  • Why cross-linking is the appropriate treatment
  • Risks of delaying treatment

3. Prior Treatment History

  • Specific contact lens types tried and failed
  • Duration of each treatment attempt
  • Reasons for discontinuation or failure

4. FDA-Approved Protocol

  • Confirmation of epithelium-off technique with iLink system
  • Appropriate dosing and administration plan
  • Expected outcomes and monitoring plan

5. Supporting References

  • FDA labeling information
  • Peer-reviewed studies on cross-linking efficacy
  • Professional society guidelines

Clinician Corner: Medical Necessity Checklist

✓ Document specific progression parameters (Kmax, pachymetry, topography)
✓ Include dates and measurements from serial examinations
✓ Explain why conservative treatments have failed
✓ Reference FDA-approved indications and protocols
✓ Cite relevant clinical guidelines and studies
✓ Specify monitoring and follow-up plans

Peer-to-Peer Review Support

If your initial PA is denied, your doctor can request a peer-to-peer (P2P) review with a Cigna medical director.

How to Support Your Doctor's P2P Call

Offer Availability Windows:

  • Ask when your doctor plans to call Cigna
  • Provide your availability for any follow-up questions
  • Ensure your contact information is current

Prepare a Concise Case Summary: Help your doctor prepare a 2-3 sentence summary:

  • "Patient has documented progressive keratoconus with Kmax increase from X to Y diopters over Z months"
  • "Conservative management with contact lenses has failed due to [specific reasons]"
  • "FDA-approved corneal cross-linking is medically necessary to halt progression"

P2P Contact Information

Your doctor should call Cigna Health Services at 1-800-882-4462, option 3 to request the peer-to-peer review.

After-Visit Summary

Keep organized records of all communications and documents related to your Photrexa approval process.

What to Save

From Your Doctor's Office:

  • Copy of the PA submission
  • Medical necessity letter
  • All supporting clinical documents
  • Submission confirmation numbers

From Cigna:

  • PA determination letter (approval or denial)
  • Any requests for additional information
  • Case reference numbers

Portal Communication

Use your Cigna member portal (MyCigna) to:

  • Track PA status
  • View determination letters
  • Upload additional documents if requested
  • Communicate with your care team
Tip: Screenshot important portal pages and save PDFs of all documents. Insurance portals sometimes have technical issues or remove old information.

Respectful Persistence

Follow up appropriately without overwhelming your healthcare team or insurance company.

Communication Cadence

Week 1-2: Allow time for initial processing
Week 3: Check status via portal or phone call
Week 4+: Follow up if no determination received

How to Escalate Politely

With Your Doctor's Office:

  • "I wanted to check on the status of my Photrexa prior authorization"
  • "Has Cigna requested any additional information?"
  • "Would it be helpful for me to call Cigna directly?"

With Cigna:

  • Reference your case number and PA submission date
  • Ask for specific reasons if denied
  • Request information about the appeals process

Appeals Playbook for California

California residents have strong appeal rights through both Cigna's internal process and the state's Independent Medical Review system.

Step-by-Step Appeals Process

1. Internal Appeal (First Level)

  • Timeline: File within 180 days of denial
  • How to file: Cigna member portal or written request
  • Documents needed: Denial letter, additional medical records, provider support letter
  • Decision timeline: 30 days (expedited: 72 hours for urgent cases)

2. Internal Appeal (Second Level)

  • Timeline: File within 60 days of first-level denial
  • Process: Similar to first level with independent reviewer
  • Decision timeline: 30 days

3. California Independent Medical Review (IMR)

  • When to file: After internal appeals are exhausted
  • Cost: Free to patients
  • Timeline: 45 days for standard, 7 days for expedited
  • Binding: Yes, Cigna must follow IMR decision
  • How to apply: DMHC website or call 888-466-2219
From our advocates: We've seen cases where patients initially denied for Photrexa were approved on appeal when their ophthalmologist provided detailed progression documentation and emphasized the FDA-approved nature of the treatment. The key was demonstrating clear medical necessity with objective measurements rather than subjective symptoms alone.

California-Specific Resources

Department of Managed Health Care (DMHC):

  • Phone: 888-466-2219
  • Website: healthhelp.ca.gov
  • Handles most HMO and managed care appeals

California Department of Insurance (CDI):

  • Phone: 800-927-4357
  • Handles some PPO and indemnity plan appeals

Common Denial Reasons & Fixes

Denial Reason How to Overturn Required Documents
Missing progression documentation Provide serial topography showing Kmax increase ≥1.0D At least 2 topography reports, 3-6 months apart
Insufficient prior treatment history Document failed contact lens trials Clinical notes with specific lens types, dates, failure reasons
Non-FDA approved protocol Confirm epithelium-off technique with iLink system Provider attestation of FDA-approved protocol
Experimental/investigational Cite FDA approval and clinical guidelines FDA labeling, peer-reviewed studies, professional guidelines
Not medically necessary Provide comprehensive clinical rationale Complete medical necessity letter with references

FAQ

How long does Cigna PA take in California? Standard prior authorization decisions are made within 5 business days. Expedited reviews for urgent cases are completed within 24-72 hours.

What if Photrexa is non-formulary on my plan? Your doctor can request a formulary exception with clinical justification. If denied, you can appeal through Cigna's internal process and California's IMR system.

Can I request an expedited appeal in California? Yes, if your condition is urgent or if delaying treatment could seriously jeopardize your health. Both Cigna and California's IMR system offer expedited timelines.

Does step therapy apply to Photrexa? Cigna may require documentation of failed conservative treatments (like contact lenses) before approving cross-linking, but this varies by plan.

What's the success rate for appeals in California? California's IMR system has varying success rates, with pharmaceutical appeals having lower overturn rates (8-13%) but higher success when proper medical necessity is demonstrated.

How much does Photrexa treatment cost? The complete procedure (drug + device + facility) typically costs $2,500-$4,000 per eye. Your out-of-pocket cost depends on your specific Cigna plan's coverage and deductible status.

When navigating insurance approvals for specialty treatments like Photrexa, having expert support can make the difference between approval and denial. Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals by analyzing payer policies and crafting point-by-point rebuttals that align with each plan's specific requirements.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage decisions depend on individual plan terms and medical circumstances. Always consult with your healthcare provider and insurance company for guidance specific to your situation. For additional help with California health insurance issues, contact the DMHC Help Center at 888-466-2219.

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