Cigna prior authorization, page 33

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
J0896	Injection, luspatercept-aamt, 0.25 mg	Master Precertification List For Health Care Providers, Pg 77 Original policy
J0897*	Injection, denosumab, 1 mg	Master Precertification List For Health Care Providers, Pg 77 Original policy
J1072	Injection, testosterone cypionate (azmiro), 1 mg	Master Precertification List For Health Care Providers, Pg 77 Original policy
J1073	Testosterone pellet, implant, 75 mg	Master Precertification List For Health Care Providers, Pg 77 Original policy
J1202	Miglustat, oral, 65 mg	Master Precertification List For Health Care Providers, Pg 77 Original policy
J1203	Injection, cipaglucosidase alfa-atga, 5 mg	Master Precertification List For Health Care Providers, Pg 77 Original policy
J1289	Injection, narsoplimab-wuug, 1 mg	Master Precertification List For Health Care Providers, Pg 77 Original policy
J1290	Injection, ecallantide, 1 mg	Master Precertification List For Health Care Providers, Pg 77 Original policy
J1299	Injection, eculizumab, 2 mg	Master Precertification List For Health Care Providers, Pg 77 Original policy
J1301	Injection, edaravone, 1 mg	Master Precertification List For Health Care Providers, Pg 77 Original policy
J1302	Injection, sutimlimab-jome, 10 mg	Master Precertification List For Health Care Providers, Pg 77 Original policy
J1303	Injection, ravulizumab-cwvz, 10 mg	Master Precertification List For Health Care Providers, Pg 77 Original policy
J1304	Injection, tofersen, 1 mg	Master Precertification List For Health Care Providers, Pg 77 Original policy
J1305	Injection, evinacumab-dgnb, 5mg	Master Precertification List For Health Care Providers, Pg 77 Original policy
J1306	Injection, inclisiran, 1 mg	Master Precertification List For Health Care Providers, Pg 77 Original policy
J1307	Injection, crovalimab-akkz, 10 mg	Master Precertification List For Health Care Providers, Pg 77 Original policy
J1322	Injection, elosulfase alfa, 1 mg	Master Precertification List For Health Care Providers, Pg 77 Original policy
J1323*	Injection, elranatamab-bcmm, 1 mg	Master Precertification List For Health Care Providers, Pg 77 Original policy
J1325	Injection, epoprostenol, 0.5 mg	Master Precertification List For Health Care Providers, Pg 77 Original policy
J1326*	Injection, zolbetuximab-clzb, 2 mg	Master Precertification List For Health Care Providers, Pg 77 Original policy
J1411	Injection, etranacogene dezaparvovec-drlb, per therapeutic dose	Master Precertification List For Health Care Providers, Pg 77 Original policy
J1412	Injection, valoctocogene roxaparvovec-rvox, per ml, containing nominal 2 x 10^13 vector genomes	Master Precertification List For Health Care Providers, Pg 77 Original policy
J1413	Injection, delandistrogene moxeparvovec-rokl, per therapeutic dose	Master Precertification List For Health Care Providers, Pg 77 Original policy
J1414	Injection, fidanacogene elaparvovec-dzkt, per therapeutic dose	Master Precertification List For Health Care Providers, Pg 77 Original policy
J1426	Injection, casimersen, 10 mg	Master Precertification List For Health Care Providers, Pg 77 Original policy
J1427	Injection, viltolarsen, 10 mg	Master Precertification List For Health Care Providers, Pg 77 Original policy
J1428	Injection, eteplirsen, 10 mg	Master Precertification List For Health Care Providers, Pg 77 Original policy
J1429	Injection, golodirsen, 10 mg	Master Precertification List For Health Care Providers, Pg 77 Original policy
J1437	Injection, ferric derisomaltose, 10 mg	Master Precertification List For Health Care Providers, Pg 78 Original policy
J1438	Injection, etanercept, 25 mg	Master Precertification List For Health Care Providers, Pg 78 Original policy
J1439	Injection, ferric carboxymaltose, 1 mg	Master Precertification List For Health Care Providers, Pg 78 Original policy
J1440	Fecal microbiota, live - jslm, 1 ml	Master Precertification List For Health Care Providers, Pg 78 Original policy
J1442*	Injection, filgrastim (g-csf), excludes biosimilars, 1 microgram - Brand name: Neupogen	Master Precertification List For Health Care Providers, Pg 78 Original policy
J1447*	Injection, tbo-filgrastim, 1 microgram	Master Precertification List For Health Care Providers, Pg 78 Original policy
J1448*	Injection, trilaciclib, 1mg	Master Precertification List For Health Care Providers, Pg 78 Original policy
J1449*	Injection, eflapegrastim-xnst, 0.1 mg	Master Precertification List For Health Care Providers, Pg 78 Original policy
J1458	Injection, galsulfase, 1 mg	Master Precertification List For Health Care Providers, Pg 78 Original policy
J1459	Injection, immune globulin (privigen), intravenous, non-lyophilized (e.g., liquid), 500 mg	Master Precertification List For Health Care Providers, Pg 78 Original policy
J1551	Injection, immune globulin (cutaquig), 100 mg	Master Precertification List For Health Care Providers, Pg 78 Original policy
J1552	Injection, immune globulin (alyglo), 100 mg	Master Precertification List For Health Care Providers, Pg 78 Original policy
J1553	Injection, immune globulin (yimmugo), 100 mg	Master Precertification List For Health Care Providers, Pg 78 Original policy
J1554	Injection, immune globulin (asceniv), 500 mg	Master Precertification List For Health Care Providers, Pg 78 Original policy
J1555	Injection, immune globulin (cuvitru), 100 mg	Master Precertification List For Health Care Providers, Pg 78 Original policy
J1556	Injection, immune globulin (bivigam), 500 mg	Master Precertification List For Health Care Providers, Pg 78 Original policy
J1557	Injection, immune globulin, (gammaplex), intravenous, non-lyophilized (e.g., liquid), 500 mg	Master Precertification List For Health Care Providers, Pg 78 Original policy
J1558	Injection, immune globulin (xembify), 100 mg	Master Precertification List For Health Care Providers, Pg 78 Original policy
J1559	Injection, immune globulin (hizentra), 100 mg	Master Precertification List For Health Care Providers, Pg 78 Original policy
J1561	Injection, immune globulin, (gamunex-c/gammaked), non-lyophilized (e.g., liquid), 500 mg	Master Precertification List For Health Care Providers, Pg 78 Original policy
J1566	Injection, immune globulin, intravenous, lyophilized (e.g., powder), not otherwise specified, 500 mg	Master Precertification List For Health Care Providers, Pg 78 Original policy
J1568	Injection, immune globulin, (octagam), intravenous, non-lyophilized (e.g., liquid), 500 mg	Master Precertification List For Health Care Providers, Pg 78 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.

Substrate makes no representation or warranty regarding the accuracy, completeness, or timeliness of the payor-specific information presented here. Providers are solely responsible for ensuring that all claims are submitted in accordance with applicable payor requirements, and Substrate assumes no liability for claim denials, underpayments, or other adverse outcomes arising from reliance on this information.