By Counterforce Health Team in StrataGraft (allogeneic cultured keratinocytes & fibroblasts in murine collagen-dsat) —

Work With Your Doctor to Get StrataGraft Approved by Cigna in Texas: Complete Prior Authorization and Appeals Guide

Answer Box: Getting StrataGraft Approved by Cigna in Texas

StrataGraft requires prior authorization from Cigna for adults 18+ with deep partial-thickness thermal burns when autografting is clinically indicated. Your burn specialist must submit facility-based PA documentation through Cigna's provider portal within 180 days, including burn depth assessment, wound measurements, and medical necessity justification. If denied, internal appeals have 70-78% success rates when supported by criterion-specific evidence and peer-to-peer reviews. Texas offers binding external review through Independent Review Organizations after internal appeals are exhausted.

Start today: Schedule a consultation with your burn specialist to document wound characteristics and begin PA submission immediately.

Table of Contents

  1. Set Your Goal: Understanding Cigna's Approval Requirements
  2. Visit Preparation: Documenting Your Case
  3. Building Your Evidence Kit
  4. Medical Necessity Letter Structure
  5. Supporting Peer-to-Peer Reviews
  6. After Your Visit: Documentation Management
  7. Respectful Persistence: Follow-Up Strategy
  8. Appeals Process in Texas
  9. FAQ

Set Your Goal: Understanding Cigna's Approval Requirements

StrataGraft approval through Cigna requires meeting specific medical criteria and following proper billing procedures. Here's what you and your burn specialist need to achieve together:

Coverage Requirements at a Glance

Requirement What It Means Documentation Needed
Age Restriction Adults 18+ only Patient demographics in PA form
Diagnosis Deep partial-thickness thermal burns ICD-10 burn codes (T20-T25 series)
Clinical Indication Autografting medically necessary Burn specialist evaluation
Billing Method Medical benefit (facility-billed) HCPCS J7353 or Q4229
Site of Care In-network burn center/hospital Provider network verification
Prior Authorization Required before treatment Complete PA submission via portal

Partnership Goals

Your role is to provide complete medical history and advocate for timely processing. Your burn specialist handles clinical documentation, PA submission, and appeals. Together, you'll ensure Cigna receives comprehensive evidence supporting medical necessity.

Note: StrataGraft must never be billed through pharmacy benefits (Express Scripts/Accredo). This results in automatic denial and delays treatment.

Visit Preparation: Documenting Your Case

Come prepared with a detailed timeline and comprehensive medical history to help your burn specialist build the strongest possible case.

Essential Information to Gather

Burn History:

  • Date and mechanism of injury
  • Initial burn assessment and treatment location
  • Total body surface area (TBSA) affected
  • Previous burn treatments and outcomes

Medical Background:

  • Current medications and allergies (especially murine, bovine, or porcine products)
  • Previous surgeries or skin grafts
  • Comorbidities that may affect healing
  • Insurance information and prior authorization history

Functional Impact:

  • How burns affect daily activities
  • Pain levels and management needs
  • Work or school limitations
  • Quality of life concerns

Questions for Your Burn Specialist

  1. "Do my burns meet Cigna's criteria for StrataGraft coverage?"
  2. "What documentation will strengthen our PA submission?"
  3. "How long does Cigna typically take for burn surgery approvals?"
  4. "What's our backup plan if the initial PA is denied?"

Building Your Evidence Kit

Work with your medical team to compile comprehensive clinical evidence that addresses Cigna's specific coverage criteria.

Required Clinical Documentation

Photographic Evidence:

  • Date-stamped clinical photographs showing burn depth and extent
  • Wound measurements in square centimeters
  • Before/after images if applicable

Laboratory and Imaging:

  • Recent lab work showing overall health status
  • Any imaging studies relevant to burn assessment
  • Allergy testing results if available

Treatment History:

  • Records of conservative wound care attempts
  • Documentation of failed standard therapies
  • Previous surgical interventions and outcomes

Supporting Literature

Your burn specialist should reference:

  • FDA labeling for StrataGraft confirming approved indications
  • Published clinical studies on StrataGraft efficacy
  • Professional burn treatment guidelines
  • Cigna's wound healing coverage policy criteria

Medical Necessity Letter Structure

The medical necessity letter is crucial for PA approval. Here's what your burn specialist should include:

Essential Components

Clinical Problem Statement:

  • Clear diagnosis with ICD-10 codes
  • Burn depth assessment confirming deep partial-thickness involvement
  • Total body surface area calculations
  • Impact on patient function and quality of life

Prior Treatment Documentation:

  • Conservative wound care attempts and outcomes
  • Why standard autografting is contraindicated or inadequate
  • Documentation of limited donor sites or comorbidities

Clinical Rationale for StrataGraft:

  • Specific advantages over alternatives
  • Expected outcomes and healing timeline
  • Dosing and application plan
  • Monitoring and follow-up strategy

Supporting Evidence:

  • References to FDA approval and clinical studies
  • Professional society guidelines
  • Peer-reviewed literature on efficacy
Tip: Request a draft of the medical necessity letter to review before submission. You can help ensure all relevant medical history is included.

Supporting Peer-to-Peer Reviews

Peer-to-peer reviews with Cigna medical directors increase approval rates by 15-20%. Here's how to support this process:

Preparation for P2P Calls

Provide Your Availability:

  • Offer flexible scheduling windows
  • Be available for brief patient history questions
  • Prepare a concise case summary highlighting key points

Key Messages to Emphasize:

  • Burn severity and extent requiring surgical intervention
  • Failed conservative treatments
  • Why StrataGraft offers superior outcomes
  • Urgency of treatment to prevent complications

During the Review

Your burn specialist will handle the clinical discussion, but you can:

  • Provide additional context about functional limitations
  • Clarify timeline of treatments and outcomes
  • Emphasize the impact of delayed treatment

After Your Visit: Documentation Management

Proper documentation management ensures smooth processing and appeals preparation.

What to Save

From Your Provider:

  • Copy of complete PA submission
  • Medical necessity letter
  • Clinical photographs and measurements
  • Treatment timeline and plan

From Cigna:

  • PA confirmation number and submission date
  • All correspondence and determination letters
  • Appeals forms and deadlines

Portal Communication

Use your patient portal to:

  • Request copies of all submitted documentation
  • Track PA status and timeline
  • Communicate updates or additional information
  • Schedule follow-up appointments
Important: Keep detailed records of all communications, including dates, times, and reference numbers.

Respectful Persistence: Follow-Up Strategy

Maintain appropriate follow-up without overwhelming your medical team or Cigna.

Timeline for Updates

Week 1-2: Confirm PA submission and tracking number Week 3: Check status if no response received Week 4+: Weekly status checks if approaching treatment deadlines

Escalation Steps

  1. Provider Office: Request status updates and assistance
  2. Cigna Member Services: Call 1-800-88-CIGNA for PA status
  3. Provider Relations: Have your doctor contact Cigna directly
  4. Appeals Process: File formal appeal if denied

Communication Scripts

For Provider Office: "I'm following up on my StrataGraft PA submitted on [date]. Can you check the status and let me know if Cigna needs additional information?"

For Cigna: "I'm calling about PA request [number] for StrataGraft submitted by [provider name]. Can you provide a status update and expected timeline?"

Appeals Process in Texas

If Cigna denies your StrataGraft PA, Texas provides strong appeal rights through multiple levels of review.

Internal Appeals Process

Appeal Level Deadline Decision Timeline Requirements
Level 1 Internal 180 days from denial 30 days (72 hours expedited) Denial letter, enhanced medical necessity documentation
Level 2 Internal 60 days from Level 1 denial 30 days Additional evidence, peer-to-peer review option

External Review in Texas

After exhausting internal appeals, Texas offers binding external review through Independent Review Organizations (IROs):

Filing Requirements:

  • Complete internal appeals first
  • Submit within 4 months of final internal denial
  • No cost to patient (Cigna pays IRO fees)

Timeline:

  • Standard review: 20 days
  • Expedited review: 5 days for urgent cases

Contact Information:

  • Texas Department of Insurance: 1-800-252-3439
  • Office of Public Insurance Counsel: 1-877-611-6742
  • IRO information line: 1-866-554-4926

Success Rates

Internal appeals for medical necessity denials have 70-78% success rates when supported by:

  • Criterion-specific evidence addressing Cigna's coverage policy
  • Peer-to-peer reviews with medical directors
  • Complete clinical documentation and photographs
  • Professional society guidelines and FDA labeling

Costs and Financial Assistance

StrataGraft is billed under your medical benefit, not pharmacy coverage:

Typical Patient Responsibility:

  • Annual medical deductible applies
  • 10-20% coinsurance after deductible (varies by plan)
  • Out-of-network penalties may apply

Financial Assistance Options:

  • Contact Mallinckrodt (StrataGraft manufacturer) for patient support programs
  • Verify with your burn center about financial assistance programs
  • Check with nonprofit burn foundations for grant opportunities

At Counterforce Health, we help patients, clinicians, and specialty pharmacies navigate complex prior authorization and appeals processes. Our platform analyzes denial letters and insurance policies to create targeted, evidence-backed appeals that turn rejections into approvals. By identifying specific denial reasons and crafting point-by-point rebuttals aligned with each payer's own rules, we help patients access critical treatments like StrataGraft more efficiently.

FAQ

Q: How long does Cigna take to approve StrataGraft PA requests? A: Standard review takes 10-15 business days. Expedited review is available for urgent cases and typically resolves within 72 hours when physician-certified harm from delay exists.

Q: What if my burn specialist says StrataGraft isn't covered by Cigna? A: StrataGraft is covered by Cigna for FDA-approved indications when proper PA procedures are followed. Request a second opinion from a burn center experienced with StrataGraft submissions.

Q: Can I appeal if Cigna denies coverage for off-label use? A: Yes, but success rates are lower. Appeals must demonstrate medical necessity with peer-reviewed evidence and professional guidelines supporting off-label use.

Q: What happens if I need StrataGraft urgently? A: Request expedited PA review and be prepared to file expedited appeals. Texas allows concurrent expedited internal and external reviews when delays would jeopardize health.

Q: Does step therapy apply to StrataGraft? A: Cigna typically requires documentation that standard burn care (conservative wound management, autografting) is inadequate or contraindicated before approving StrataGraft.

Q: How do I verify my burn center is in-network with Cigna? A: Call the number on your insurance card or check Cigna's online provider directory. Out-of-network treatment may result in higher costs and different PA requirements.

Q: What if Cigna says StrataGraft is experimental? A: Counter with FDA approval documentation and published clinical studies. StrataGraft received FDA approval for deep partial-thickness thermal burns in adults.

Sources and Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage decisions depend on individual circumstances and plan details. Always consult with your healthcare provider and insurance company for specific guidance regarding your situation. For additional assistance with insurance appeals in Texas, contact the Texas Department of Insurance at 1-800-252-3439.

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