Cigna prior authorization, page 32

Requirements

Read the care-management columns separately. Complete, PHS+, Preferred, and Basic Standard do not collapse into one Cigna answer. The long descriptor is blank because no AMA-licensed CPT file was available to copy.

Cigna precertification list

Cigna master precertification list

Cigna precertification

CPT code lookup

Prior authorization codes

Prior authorization codes
Code	Description	Source
J0222	Injection, Patisiran, 0.1 mg	Master Precertification List For Health Care Providers, Pg 75 Original policy
J0223	Injection, givosiran, 0.5 mg	Master Precertification List For Health Care Providers, Pg 75 Original policy
J0224	Injection, lumasiran, 0.5 mg	Master Precertification List For Health Care Providers, Pg 75 Original policy
J0225	Injection, vutrisiran, 1 mg	Master Precertification List For Health Care Providers, Pg 75 Original policy
J0256	Injection, alpha 1 proteinase inhibitor (human), not otherwise specified, 10 mg	Master Precertification List For Health Care Providers, Pg 75 Original policy
J0257	Injection, alpha 1 proteinase inhibitor (human), (glassia), 10 mg	Master Precertification List For Health Care Providers, Pg 75 Original policy
J0364	Injection, apomorphine hydrochloride, 1 mg	Master Precertification List For Health Care Providers, Pg 75 Original policy
J0470	Injection, dimercaprol, per 100 mg	Master Precertification List For Health Care Providers, Pg 75 Original policy
J0485	Injection, belatacept, 1 mg	Master Precertification List For Health Care Providers, Pg 75 Original policy
J0490	Injection, belimumab, 10 mg	Master Precertification List For Health Care Providers, Pg 75 Original policy
J0491	Injection, anifrolumab-fnia, 1 mg	Master Precertification List For Health Care Providers, Pg 75 Original policy
J0517	Injection, benralizumab, 1 mg	Master Precertification List For Health Care Providers, Pg 75 Original policy
J0567	Injection, cerliponase alfa, 1 mg	Master Precertification List For Health Care Providers, Pg 75 Original policy
J0570	Buprenorphine implant, 74.2 mg	Master Precertification List For Health Care Providers, Pg 75 Original policy
J0584	Injection, burosumab-twza 1 mg	Master Precertification List For Health Care Providers, Pg 76 Original policy
J0585	Injection, onabotulinumtoxina, 1 unit	Master Precertification List For Health Care Providers, Pg 76 Original policy
J0586	Injection, abobotulinumtoxina, 5 units	Master Precertification List For Health Care Providers, Pg 76 Original policy
J0587	Injection, rimabotulinumtoxinb, 100 units	Master Precertification List For Health Care Providers, Pg 76 Original policy
J0588	Injection, incobotulinumtoxin a, 1 unit	Master Precertification List For Health Care Providers, Pg 76 Original policy
J0589	Injection, daxibotulinumtoxina-lanm, 1 unit	Master Precertification List For Health Care Providers, Pg 76 Original policy
J0591	Injection, deoxycholic acid, 1 mg	Master Precertification List For Health Care Providers, Pg 76 Original policy
J0593	Injection, lanadelumab-flyo, 1 mg (code may be used for medicare when drug administered under direct supervision of a physician, not for use when drug is self-administered)	Master Precertification List For Health Care Providers, Pg 76 Original policy
J0596	Injection, c1 esterase inhibitor (recombinant), ruconest, 10 units	Master Precertification List For Health Care Providers, Pg 76 Original policy
J0597	Injection, c-1 esterase inhibitor (human), berinert, 10 units	Master Precertification List For Health Care Providers, Pg 76 Original policy
J0598	Injection, c-1 esterase inhibitor (human), cinryze, 10 units	Master Precertification List For Health Care Providers, Pg 76 Original policy
J0599	Injection, c-1 esterase inhibitor (human), (haegarda), 10 units	Master Precertification List For Health Care Providers, Pg 76 Original policy
J0600	Injection, edetate calcium disodium, up to 1000 mg	Master Precertification List For Health Care Providers, Pg 76 Original policy
J0606	Injection, etelcalcetide, 0.1 mg	Master Precertification List For Health Care Providers, Pg 76 Original policy
J0614*	Injection, treosulfan, 50 mg	Master Precertification List For Health Care Providers, Pg 76 Original policy
J0638	Injection, canakinumab, 1 mg	Master Precertification List For Health Care Providers, Pg 76 Original policy
J0641*	Injection, levoleucovorin, not otherwise specified, 0.5 mg	Master Precertification List For Health Care Providers, Pg 76 Original policy
J0642*	Injection, levoleucovorin (khapzory), 0.5 mg	Master Precertification List For Health Care Providers, Pg 76 Original policy
J0717	Injection, certolizumab pegol, 1 mg (code may be used for medicare when drug administered under the direct supervision of a physician, not for use when drug is self administered)	Master Precertification List For Health Care Providers, Pg 76 Original policy
J0725	Injection, chorionic gonadotropin, per 1,000 usp units	Master Precertification List For Health Care Providers, Pg 76 Original policy
J0741	Injection, cabotegravir and rilpivirine, 2mg/3mg	Master Precertification List For Health Care Providers, Pg 76 Original policy
J0775	Injection, collagenase, clostridium histolyticum, 0.01 mg	Master Precertification List For Health Care Providers, Pg 76 Original policy
J0791	Injection, crizanlizumab-tmca, 5 mg	Master Precertification List For Health Care Providers, Pg 76 Original policy
J0799	Fda approved prescription drug, only for use as hiv pre-exposure prophylaxis (not for use as treatment of hiv), not otherwise classified	Master Precertification List For Health Care Providers, Pg 76 Original policy
J0801	Injection, corticotropin (acthar gel), up to 40 units	Master Precertification List For Health Care Providers, Pg 76 Original policy
J0802	Injection, corticotropin (ani), up to 40 units	Master Precertification List For Health Care Providers, Pg 76 Original policy
J0870*	Injection, imetelstat, 1 mg	Master Precertification List For Health Care Providers, Pg 76 Original policy
J0879	Injection, difelikefalin, 0.1 microgram, (for esrd on dialysis)	Master Precertification List For Health Care Providers, Pg 76 Original policy
J0881*	Injection, darbepoetin alfa, 1 microgram (non-esrd use) - Brand name: Aranesp	Master Precertification List For Health Care Providers, Pg 76 Original policy
J0882	Injection, darbepoetin alfa, 1 microgram (for esrd on dialysis)	Master Precertification List For Health Care Providers, Pg 76 Original policy
J0885*	Injection, epoetin alfa, (for non-esrd use), 1000 units	Master Precertification List For Health Care Providers, Pg 76 Original policy
J0887	Injection, epoetin beta, 1 microgram, (for esrd on dialysis)	Master Precertification List For Health Care Providers, Pg 77 Original policy
J0888	Injection, epoetin beta, 1 microgram, (for non esrd use)	Master Precertification List For Health Care Providers, Pg 77 Original policy
J0890	Injection, peginesatide, 0.1 mg (for esrd on dialysis)	Master Precertification List For Health Care Providers, Pg 77 Original policy
J0893*	Injection, decitabine (sun pharma), not therapeutically equivalent to J0894, 1 mg	Master Precertification List For Health Care Providers, Pg 77 Original policy
J0894*	Injection, decitabine, 1 mg	Master Precertification List For Health Care Providers, Pg 77 Original policy

Removed codes

Cigna codes removed from the master precertification list

Sources

Disclaimer

The information provided on this page is for general informational purposes only and does not constitute billing, coding, or reimbursement advice. Nothing on this page should be relied upon as a substitute for clinician assessment, professional billing guidance, or as a definitive statement of any payor's billing requirements or policies.

Payor agreements, fee schedules, and billing policies vary and are subject to change. Before submitting any claims related to maternity care services, including claims affected by the 2027 CPT code revisions, please consult the applicable payor agreements, coverage policies, and billing guidelines to confirm current requirements for their specific payor contracts.

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