CurrentCignaPolicy V110120

Oxervate (cenegermin-bkbj) prior authorization for neurotrophic keratitis

This document is a Cigna prior authorization request form governing coverage requests for Oxervate (cenegermin-bkbj), primarily for treatment of neurotrophic keratitis and submitted by prescribing providers/ophthalmologists. It affects providers seeking pre-authorization for acquisition and administration of this specialty ophthalmic drug.

Policy Summary

PayerCigna

PolicyOxervate (cenegermin-bkbj) prior authorization for neurotrophic keratitis

Policy CodePolicy V110120

Change TypeNo material change noted

Effective DateN/A

Next Review DateN/A

Key ActionSubmit a completed prior authorization form including prescriber specialty, diagnosis and disease stage, prior therapy details, and source of medication (Accredo preferred).

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

5 business daysstandard response time for prescription drug coverage requests

fax (855) 840-1678fax number to submit completed form

phone (800) 882-4462phone for urgent requests

AccredoCigna's nationally preferred specialty pharmacy option listed

Coverage and Medical Necessity Criteria

Medical necessity criteria

Covered when ALL of the following are met

Primary criteria: 1) The medication requested is Oxervate (cenegermin-bkbj) for the diagnosis of neurotrophic keratitis; 2) The prescriber is an ophthalmologist or the drug is prescribed in consultation with an ophthalmologist (attestation required on the form); 3) For initiation of therapy: documentation that the patient has stage 2 (moderate) or stage 3 (severe) neurotrophic keratitis; 4) For continuation of therapy: documentation that an additional course is needed due to partial response or recurrence, or other clinical support for continued use is provided; 5) The completed form includes relevant patient and prescriber identifiers and clinical information (disease stage, prior therapy, directions/dose/quantity/duration, and concurrent therapies) as requested on the form.

Form specifically asks whether therapy is new or continued, stage 2 or 3 disease, and whether additional course is due to partial response or recurrence.

The form does not list any explicit exclusions for Oxervate; it provides a checkbox to indicate the diagnosis as neurotrophic keratitis or an option to specify other diagnosis. Because no exclusion conditions are named on the form, coverage determinations hinge on whether the submitted diagnosis and supporting clinical information meet the medical necessity criteria requested on the form.

Providers should complete the diagnosis field exactly as appropriate (selecting neurotrophic keratitis when applicable or specifying another diagnosis in the other line) and include accompanying clinical details requested elsewhere on the form to allow an accurate coverage review.

Policy Summary

PayerCigna

PolicyOxervate (cenegermin-bkbj) prior authorization for neurotrophic keratitis

Policy CodePolicy V110120

Change TypeNo material change noted

Effective DateN/A

Next Review DateN/A

Key ActionSubmit a completed prior authorization form including prescriber specialty, diagnosis and disease stage, prior therapy details, and source of medication (Accredo preferred).

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

The form contains no discrete list labeled “Not Medically Necessary.” Instead, it requires submission of specific clinical elements — including whether the prescriber is an ophthalmologist or consulted with one, disease stage, prior therapy and justification for continued therapy — that are used to assess medical necessity.

If required clinical details are missing or incomplete (for example, failure to attest to prescriber specialty, omission of disease stage such as stage 2 or stage 3, or lack of documentation supporting additional courses for continued therapy), the request may be denied for lack of sufficient medical justification.

Procedure and Diagnosis Codes

Procedure Codes (to be supplied)mixed

CPT Code(s):

CPT Code(s) — blank line for provider to supply

Diagnosis Codes (to be supplied)ICD-10

ICD10:

ICD-10 diagnosis code(s) — blank line for provider to supply

Provider Requirements and Submission Actions

Prior Authorization

Prior Authorization Required

Prior authorization is required for Oxervate (cenegermin) and must be submitted via the Cigna specialty drug prior authorization process. Include reason for new start vs continuation and, for continued therapy, justification for an additional course (see prior therapy documentation).

Use Cigna’s prior authorization form and complete all asterisked fields (see Required documentation).
For continuation requests, document why an additional course is needed (partial response, recurrence, or other clinical rationale).

Step Therapy

Prior Therapy Documentation

Provide documentation of prior therapies attempted and the clinical response. If requesting an additional course of therapy, state whether prior treatment produced only a partial response or the patient experienced recurrence and include dates, agents, doses, and duration.

List prior topical/systemic therapies and dates of use.
Describe objective/subjective response (partial response, recurrence, failure, intolerance).
If prior ophthalmic procedures or biologic agents were used, include details and outcomes.

Documentation Required

Required Documentation

Complete all required patient and prescriber fields on the prior authorization form. Fields marked with an asterisk (*) are mandatory and requests missing these items may be returned or denied.

Patient: *Patient Name, *Cigna ID, *Date of Birth, Patient address and phone.
Prescriber: *DEA, *NPI or TIN, Physician name, Specialty, Office contact, Office phone and fax, Office address.
Clinical: ICD-10 diagnosis code, Directions for use, Dose, Quantity, Duration of therapy, Where medication will be obtained (Accredo, physician stock, infusion vendor, etc.), CPT code(s) and site of service.
Clinical information: disease stage, prior therapy details, performance status, names/doses/schedule of concurrent agents.

Denial Risk

Triggers for Denial

Requests may be denied if required clinical attestations or documentation are missing or inadequate. Ensure the prescriber is an ophthalmologist or that there is documented consultation with an ophthalmologist when indicated, and confirm stage 2 or 3 disease for neurotrophic keratitis when applicable.

Missing ophthalmologist attestation or consultation — denial risk.
No documentation of stage 2 (moderate) or stage 3 (severe) disease when required — denial risk.
Incomplete prior therapy documentation or lack of rationale for additional course — denial risk.
Missing required asterisked fields (DEA, NPI/TIN, Cigna ID, DOB) — denial risk.

Key Definitions

Diagnosis (form)

Diagnosis on formNeurotrophic keratitis

Alternate option on formOther (provider to specify)

Where recordedListed under 'Diagnosis related to use' on the prior authorization form

Disease stage (clinical assessment)

Required disease stage for considerationStage 2 (moderate) or Stage 3 (severe)

Response option on formYes/No checkbox asking if the patient has stage 2 or 3 disease

Additional required clinical detailsForm requests additional pertinent information including disease stage, prior therapy, performance status, and concurrent agents' names/doses/schedules

Background and Indication

Oxervate (cenegermin-bkbj) is a topical biologic therapy requested on this prior authorization form for the treatment of neurotrophic keratitis. The form specifically asks whether the patient has stage 2 (moderate) or stage 3 (severe) disease, and it collects prior therapy, dose, quantity and duration, and whether the request is a new start or continued therapy to support the medical necessity review.

For continuation requests the form asks whether the patient needs an additional course due to partial response or recurrence, and requests clinical justification if continued therapy is sought. The collected information is used to determine whether the requested Oxervate treatment meets the criteria for coverage.