By Counterforce Health Team in Prolastin-C (alpha1-proteinase inhibitor) —

Work With Your Doctor to Get Prolastin-C Approved by Cigna in Washington: Provider Collaboration Guide

Answer Box: Your Path to Prolastin-C Coverage

Cigna covers Prolastin-C for alpha-1 antitrypsin deficiency with prior authorization requiring: age ≥18, AAT levels <80 mg/dL, lung disease evidence (FEV1 <80% predicted), non-smoking status, and pulmonologist involvement. First step: Schedule a visit with your doctor to document these criteria and submit Cigna's PA form. In Washington, you have 180 days to appeal denials through internal review, then external review via an Independent Review Organization. Start with Cigna's coverage policy.

Table of Contents

Set Your Goal: Understanding Approval Requirements

Your partnership with your doctor centers on proving Prolastin-C is medically necessary for your alpha-1 antitrypsin (AAT) deficiency. Cigna requires specific clinical documentation that only your healthcare team can provide.

Coverage Criteria Checklist

Requirement What It Means Your Role
Age ≥18 years Must be adult patient Verify birth date in records
AAT level <80 mg/dL Severe deficiency confirmed Request lab results copy
Lung disease evidence FEV1 <80% predicted, emphysema Schedule pulmonary function tests
Non-smoking status Current non-smoker Discuss smoking cessation timeline
Pulmonologist involvement Specialist consultation required Request referral if needed

Source: Cigna Alpha-1 Proteinase Inhibitors Policy

Your primary goal: Help your doctor compile complete documentation that addresses each criterion systematically.

Visit Preparation: Documenting Your Case

Come to your appointment prepared with a comprehensive timeline of your condition and treatment history.

Essential Information to Gather

Symptom Timeline:

  • When you first noticed breathing difficulties
  • Progression of shortness of breath, fatigue, or cough
  • Impact on daily activities (walking, climbing stairs, work)
  • Any hospitalizations or emergency visits

Treatment History:

  • Previous medications tried (bronchodilators, corticosteroids)
  • Outcomes and side effects experienced
  • Pulmonary rehabilitation attempts
  • Oxygen therapy use

Family History:

  • Known AAT deficiency in relatives
  • Early emphysema or liver disease in family
  • Genetic testing results for family members
Tip: Create a one-page summary with dates, medications, and outcomes. This helps your doctor quickly understand your journey and strengthens the medical necessity case.

Building Your Evidence Kit

Work with your doctor's office to compile the clinical evidence Cigna expects to see.

Required Documentation

Laboratory Evidence:

  • Serum AAT level (must be <80 mg/dL or <11 µmol/L)
  • Genotype/phenotype testing confirming severe deficiency (Pi*ZZ most common)
  • Recent inflammatory markers to rule out acute illness affecting AAT levels

Pulmonary Function Tests:

  • Spirometry showing FEV1 <80% predicted
  • FEV1/FVC ratio <70% confirming obstruction
  • Lung volumes and DLCO if available

Imaging Studies:

  • High-resolution CT chest showing emphysema
  • Basilar-predominant pattern typical of AAT deficiency
  • Comparison with previous imaging if available

Clinical Notes:

  • Pulmonologist consultation documenting diagnosis
  • Treatment recommendations and rationale
  • Smoking cessation confirmation and timeline

Organizing Your Evidence

Create a shared folder (physical or digital) with your doctor's office containing:

  1. All lab results in chronological order
  2. Imaging reports with radiologist interpretations
  3. Pulmonary function test results
  4. Specialist consultation notes
  5. Medication trial documentation

Medical Necessity Letter Structure

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

Essential Components

1. Patient Identification & Diagnosis

  • Full name, date of birth, insurance ID
  • Primary diagnosis: Alpha-1 antitrypsin deficiency with emphysema
  • ICD-10 codes: E88.01 (AAT deficiency), J43.9 (emphysema)

2. Clinical Rationale

  • Specific AAT level and genotype results
  • Pulmonary function test findings
  • Imaging evidence of emphysema
  • Current symptom severity and functional impact

3. Treatment History & Rationale

  • Previous therapies attempted and outcomes
  • Why standard COPD treatments are insufficient
  • Evidence supporting augmentation therapy

4. Risks of Delayed Treatment

  • Progressive lung damage without replacement therapy
  • Potential for respiratory failure
  • Impact on quality of life and mortality risk

5. Supporting References

  • FDA approval for AAT deficiency treatment
  • Clinical guidelines from pulmonary societies
  • Peer-reviewed studies on efficacy
Clinician Corner: The letter should emphasize that AAT deficiency is a distinct condition requiring specific replacement therapy, not just standard COPD management. Reference the FDA-approved indication and include specific lab values and PFT results.

Peer-to-Peer Review Support

If Cigna requests a peer-to-peer review, your doctor will speak directly with a Cigna medical director. Here's how you can support this process:

Before the Call

Provide Your Doctor:

  • Concise case summary (one page maximum)
  • Key lab values and dates
  • Most compelling imaging findings
  • Treatment timeline with specific outcomes

Schedule Coordination:

  • Offer flexible availability windows
  • Confirm your doctor's preferred contact method
  • Ensure all relevant records are immediately accessible

Key Talking Points for Your Doctor

  1. Unique pathophysiology: AAT deficiency causes specific panacinar emphysema requiring replacement therapy
  2. Genetic confirmation: Severe genotype (Pi*ZZ) with quantitative deficiency
  3. Appropriate candidate: Non-smoker with moderate lung disease (FEV1 30-65% predicted)
  4. Standard of care: Augmentation therapy is FDA-approved and guideline-recommended

After Your Visit: Documentation Strategy

Maximize the value of each healthcare interaction by systematically documenting outcomes.

What to Request After Each Visit

Visit Summary:

  • Copy of provider notes from the appointment
  • Updated problem list and medication changes
  • Any new test orders or referrals

Portal Communications:

  • Screenshots of important messages
  • Copies of test results as they become available
  • Documentation of medication approvals or denials

Insurance Communications:

  • All correspondence from Cigna
  • Prior authorization request confirmations
  • Denial letters with specific reasons cited

Organizing Your Records

Counterforce Health helps patients navigate complex prior authorization processes by organizing clinical evidence and crafting targeted appeals. Their platform can help ensure your documentation meets payer-specific requirements and deadlines.

Create a chronological file system:

  • Current PA Request: All documents related to your active request
  • Clinical Evidence: Lab results, imaging, PFTs organized by date
  • Insurance Communications: All Cigna correspondence
  • Provider Notes: Visit summaries and recommendations

Respectful Persistence: Follow-Up Timeline

Maintain appropriate follow-up without overwhelming your healthcare team.

Week 1-2 After Submission:

  • Confirm PA request was received by Cigna
  • Verify all required documents were included
  • Check for any immediate requests for additional information

Week 3-4:

  • If no response, contact your doctor's office for status update
  • Ask if peer-to-peer review has been requested
  • Confirm next steps if denial is received

Monthly Thereafter:

  • Brief check-in on any ongoing appeals
  • Update on any changes in symptoms or condition
  • Coordinate any new testing or documentation needs

Escalation Guidelines

When to Escalate:

  • No response after 30 days (Cigna's standard review period)
  • Request for inappropriate additional testing
  • Denial based on incorrect information
  • Repeated requests for already-submitted documents

How to Escalate Politely:

  • "I wanted to follow up on my prior authorization request submitted on [date]"
  • "Could you help me understand what additional information might be helpful?"
  • "I'm concerned about delays in accessing necessary treatment"

Appeals Process in Washington

Washington state provides strong consumer protections for insurance appeals, giving you multiple levels of review.

Internal Appeals Timeline

First Level Internal Review:

  • Must be filed within 180 days of denial
  • Cigna has 30 days to review (15 for expedited)
  • Submit additional clinical evidence if available

Second Level Internal Review:

  • Available if first appeal is denied
  • Additional 30 days for Cigna review
  • Consider new specialist opinions or updated testing

External Review Process

After exhausting internal appeals, Washington residents can request external review through an Independent Review Organization (IRO).

How to Request External Review:

  • File within 180 days of final internal denial
  • Contact Washington Office of the Insurance Commissioner at 1-800-562-6900
  • Submit request form and all relevant documentation

IRO Review Process:

  • Independent medical specialists review your case
  • IRO has 30 days to make determination (72 hours for expedited)
  • Decision is binding on Cigna if approved

Source: Washington State Insurance Commissioner Appeals Process

Common Denial Reasons & Solutions

Denial Reason How to Address Required Documentation
Insufficient AAT levels Provide quantitative serum AAT test Lab report showing <80 mg/dL
Lack of genetic confirmation Submit genotype/phenotype testing Pi*ZZ or equivalent severe genotype
Inadequate lung disease evidence Comprehensive pulmonary evaluation PFTs, chest CT, specialist consultation
Smoking history concerns Document cessation timeline Provider attestation of non-smoking status
Non-preferred brand Request formulary exception Clinical rationale for Prolastin-C specifically

Step Therapy Challenges

Cigna may require trial of preferred alternatives (Glassia) before approving Prolastin-C. Document any clinical reasons for brand preference:

  • Previous experience with specific formulation
  • Administration considerations (liquid vs. powder)
  • Tolerability differences between products

FAQ: Working With Your Provider

How long does Cigna prior authorization typically take? Standard review takes up to 30 days, though many decisions come within 15 days. Expedited review (for urgent cases) is completed within 72 hours.

What if my pulmonologist is not in Cigna's network? Out-of-network specialists can still provide consultation notes and recommendations. Your in-network primary care doctor can coordinate care and submit the prior authorization.

Can I appeal if Prolastin-C is not on Cigna's formulary? Yes, you can request a formulary exception by demonstrating medical necessity for the specific brand over covered alternatives.

What counts as "medical necessity" for Prolastin-C? Cigna requires documented AAT deficiency with emphysema, appropriate lung function parameters, and evidence that standard COPD treatments are insufficient.

How often do appeals succeed in Washington? While specific statistics vary, Washington's strong external review process means many denials are overturned when proper clinical evidence is provided. The state's Independent Review Organizations are required to make decisions based on medical evidence, not cost considerations.

Should I involve my specialty pharmacy in the appeal process? Yes, specialty pharmacies like Accredo often have dedicated prior authorization teams that can help coordinate documentation and follow up on pending requests.

About This Guide: This information is for educational purposes and does not constitute medical advice. Always work with your healthcare provider to determine the most appropriate treatment for your condition.

Need Help? Counterforce Health specializes in turning insurance denials into successful appeals by organizing clinical evidence and crafting targeted, payer-specific responses that meet procedural requirements.

Sources & Further Reading

This guide was last updated in January 2026. Insurance policies and state regulations may change. Always verify current requirements with your insurer and healthcare provider.

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