Blog

Cigna Dupixent Coverage: How to Get Prior Authorization?

Securing insurance pre-certification for a medication like Dupixent to manage severe asthma under Cigna’s coverage can feel overwhelming, especially with all the paperwork and specific requirements. But don’t worry—by understanding each step and gathering the right documents, you and your healthcare provider can work together to improve your chances of approval. Let’s walk through the process together so you can feel confident about getting the support you need to manage your asthma effectively.

Insurance Company Overview

Cigna is one of the major players in the health insurance industry, offering a wide range of plans that include health, dental, and disability coverage. When it comes to medications like Dupixent, Cigna requires a pre-certification (also known as prior authorization) to confirm that the treatment is medically necessary. This step helps both you and the insurance company make sure Dupixent is truly the best choice for your specific needs. For Cigna, this is part of managing costs responsibly and ensuring patients receive the right care, not only for effectiveness but also for safety.

Why Does Dupixent Need Pre-Certification?

Dupixent, or dupilumab, is a specialized medication that’s often prescribed as an add-on maintenance treatment for people aged six and older with moderate-to-severe asthma. Specifically, it’s used in cases with an eosinophilic phenotype (a form of asthma characterized by high levels of eosinophils, a type of white blood cell) or for patients who rely on oral corticosteroids to control their symptoms. Because Dupixent is a biologic therapy—a type of treatment that can be costly and complex—insurance providers like Cigna require pre-certification. This process ensures that Dupixent is truly necessary for managing your asthma and that it’s prescribed in line with clinical guidelines.

Step-by-Step Guide to Getting Pre-Certification for Dupixent with Cigna

Step 1: Consult with Your Healthcare Provider

The process begins with a conversation with your healthcare provider. Discuss your asthma symptoms, your medical history, and any treatments you’ve already tried. Your doctor will assess whether Dupixent is an appropriate next step for you. If Dupixent is recommended, your provider will start the pre-certification process with Cigna.

This step is crucial, as Cigna needs evidence of medical necessity for Dupixent. Your provider will need to gather documentation that demonstrates why other treatments may not be effective for you or why they aren’t ideal given your condition. This includes details of your diagnosis, symptom history, and previous medications, all of which paint a picture of why Dupixent is being considered.

Step 2: Gather All Necessary Medical Documentation

Cigna requires a comprehensive set of medical records to support the pre-certification request. Work with your healthcare provider to ensure they include the following essential documents:

• Diagnosis Details: This should confirm that you have moderate-to-severe asthma with an eosinophilic phenotype, or that you depend on oral corticosteroids for asthma control.
• Treatment History: Records of past asthma treatments, especially inhaled corticosteroids and other controller medications, including whether they were effective or not.
• Laboratory Results: Recent blood tests showing your eosinophil count or other relevant lab work that supports the diagnosis.
• Clinical Notes: Detailed notes from your healthcare provider documenting asthma exacerbations (flare-ups), any hospitalizations due to asthma, and the overall progression of your condition.

Providing a complete and detailed set of records can make all the difference. The more thorough the documentation, the less likely Cigna will need additional information, which helps prevent delays.

Step 3: Submit the Prior Authorization Request

Next, your healthcare provider’s office will submit Cigna’s specific prior authorization form for Dupixent, along with all supporting documentation. This form is designed to provide Cigna with detailed information about your asthma, your medical history, and why Dupixent is being prescribed.

Each section of the form needs to be filled out accurately. Mistakes or incomplete sections can cause delays in processing, so it’s wise to double-check everything before submission. If your provider’s office has a team dedicated to insurance approvals, they’ll likely handle this process for you, ensuring everything is in order.

Step 4: Follow Up on the Submission

Once the prior authorization request is submitted, keep in close contact with your healthcare provider to monitor the status. Cigna usually processes requests within a set timeframe, often between 5 to 10 business days for standard requests. If it’s an urgent case, your provider can request an expedited review, which may shorten this timeframe.

Following up regularly can make a big difference. Sometimes, Cigna may ask for additional information or clarification, and staying proactive with your provider ensures these requests are addressed quickly. This way, you avoid unnecessary delays and keep the process moving forward.

Step 5: Understand the Decision and Next Steps

After reviewing your pre-certification request, Cigna will either approve or deny the authorization:

• Approval: If Cigna approves the request, they’ll notify your healthcare provider, and you’ll be able to proceed with getting your Dupixent treatment. Your provider will help you schedule the injections and discuss any additional details with you.
• Denial: If the request is denied, Cigna will explain the reason for the decision. Don’t be discouraged—denials aren’t uncommon, and they don’t mean you’re out of options. You and your provider can review the denial and, if appropriate, submit an appeal. This typically involves providing more documentation or addressing specific points that Cigna raised in their denial notice.

ICD and CPT Codes Explained

When it comes to pre-certification, accurate coding is essential. Both ICD (International Classification of Diseases) and CPT (Current Procedural Terminology) codes play an important role:

• ICD Codes: These represent your diagnosis. For example, if you have severe asthma with an eosinophilic phenotype, your healthcare provider might use ICD-10 code J82 (Pulmonary eosinophilia, not elsewhere classified). These codes give Cigna a clear understanding of your condition.
• CPT Codes: These codes are used for procedures and treatments. For Dupixent, a CPT code would indicate the injection procedure itself. The exact code depends on how the medication is administered and any additional services associated with the treatment.

Accurate coding helps Cigna quickly interpret the medical necessity of Dupixent, making the approval process smoother. Your provider’s billing team will ensure the right codes are used, but it’s helpful to know these basics.

Frequently Asked Questions (FAQs)

How long does Cigna take to process a prior authorization request for Dupixent?

Cigna typically processes requests within 5 to 10 business days for standard cases, but urgent requests may be reviewed more quickly. Keep in touch with your healthcare provider to stay updated on the status.

What if my prior authorization request is denied?

If denied, you can appeal the decision. Work with your healthcare provider to gather additional supporting information and submit an appeal to Cigna for reconsideration. Often, more detailed documentation can lead to approval upon appeal.

Does Cigna cover Dupixent for all asthma patients?

Cigna covers Dupixent for patients aged 6 and older with moderate-to-severe asthma characterized by an eosinophilic phenotype or those who rely on oral corticosteroids, as long as they meet Cigna’s specific medical criteria.

Should I start Dupixent treatment before receiving pre-certification approval?

No, it’s important to wait for Cigna’s approval to ensure coverage. Starting treatment without approval may lead to significant out-of-pocket expenses.

How can I check the status of my prior authorization request?

You can contact your healthcare provider’s office, as they’ll handle communication with Cigna. You can also call Cigna’s customer service for an update if needed.

What Did We Learn?

1. Partner with Your Provider: Their expertise and thorough documentation are critical to obtaining pre-certification approval.
2. Comprehensive Records Matter: Include detailed medical history, lab results, and treatment notes to strengthen your case.
3. Follow Up Proactively: Regularly check on the status to avoid delays and handle any requests for extra information promptly.
4. Appeals Are an Option: If denied, you have the right to appeal and submit additional documentation for reconsideration.

Healthcare providers can save up to 70% on staffing costs by outsourcing administrative tasks like prior authorizations and insurance verifications to Staffingly, Inc., which offers 24/7 support, efficient case management, and more patient care time.

Disclaimer

The information in our posts is meant to inform and educate both healthcare providers and readers seeking a better understanding of the prior authorization process. However, it is not a substitute for professional advice. Insurance requirements, policies, and approval processes can vary widely and change over time. For accurate guidance, healthcare providers should consult directly with insurers or use professional resources, while patients should reach out to their insurance providers or healthcare professionals for advice specific to their situation.

This content does not establish any patient-caregiver or client-service relationship. Staffingly, Inc. assumes no liability for actions taken based on information provided in these posts.

For tailored support and professional services,

please contact Staffingly, Inc. at (800) 489-5877

Email : support@staffingly.com