Cigna prior authorization, page 34

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
J1569	Injection, immune globulin, (gammagard liquid/gammagard liquid erc), 500 mg	Master Precertification List For Health Care Providers, Pg 78 Original policy
J1572	Injection, immune globulin, (flebogamma/flebogamma dif), intravenous, non-lyophilized (e.g., liquid), 500 mg	Master Precertification List For Health Care Providers, Pg 78 Original policy
J1575	Injection, immune globulin/hyaluronidase, (hyqvia), 100 mg immuneglobulin	Master Precertification List For Health Care Providers, Pg 78 Original policy
J1576	Injection, immune globulin (panzyga), intravenous, non-lyophilized (e.g., liquid), 500 mg	Master Precertification List For Health Care Providers, Pg 78 Original policy
J1577	Injection, immune globulin (qivigy), 100 mg	Master Precertification List For Health Care Providers, Pg 78 Original policy
J1595	Injection, glatiramer acetate, 20 mg	Master Precertification List For Health Care Providers, Pg 78 Original policy
J1599	Injection, immune globulin, intravenous, non-lyophilized (e.g., liquid), not otherwise specified, 500 mg	Master Precertification List For Health Care Providers, Pg 78 Original policy
J1602	Injection, golimumab, 1 mg, for intravenous use	Master Precertification List For Health Care Providers, Pg 78 Original policy
J1628	Injection, guselkumab, 1 mg	Master Precertification List For Health Care Providers, Pg 78 Original policy
J1632	Injection, brexanolone, 1 mg	Master Precertification List For Health Care Providers, Pg 78 Original policy
J1675	Injection, histrelin acetate, 10 micrograms	Master Precertification List For Health Care Providers, Pg 79 Original policy
J1726	Injection, hydroxyprogesterone caproate, (makena), 10 mg	Master Precertification List For Health Care Providers, Pg 79 Original policy
J1743	Injection, idursulfase, 1 mg	Master Precertification List For Health Care Providers, Pg 79 Original policy
J1744	Injection, icatibant, 1 mg	Master Precertification List For Health Care Providers, Pg 79 Original policy
J1745	Injection, infliximab, excludes biosimilar, 10 mg	Master Precertification List For Health Care Providers, Pg 79 Original policy
J1746	Injection, ibalizumab-uiyk, 10 mg	Master Precertification List For Health Care Providers, Pg 79 Original policy
J1747	Injection, spesolimab-sbzo, 1 mg	Master Precertification List For Health Care Providers, Pg 79 Original policy
J1748	Injection, infliximab-dyyb (zymfentra), 10 mg	Master Precertification List For Health Care Providers, Pg 79 Original policy
J1757	Injection, tividenofusp alfa-eknm, 1 mg	Master Precertification List For Health Care Providers, Pg 79 Original policy
J1786	Injection, imiglucerase, 10 units	Master Precertification List For Health Care Providers, Pg 79 Original policy
J1809	Injection, fosdenopterin, 0.1 mg	Master Precertification List For Health Care Providers, Pg 79 Original policy
J1818	Injection, pegzilarginase-nbln, 0.05 mg	Master Precertification List For Health Care Providers, Pg 79 Original policy
J1823	Injection, inebilizumab-cdon, 1 mg	Master Precertification List For Health Care Providers, Pg 79 Original policy
J1826	Injection, interferon beta-1a, 30 mcg	Master Precertification List For Health Care Providers, Pg 79 Original policy
J1830	Injection, interferon beta-1b, 0.25 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 79 Original policy
J1930*	Injection, lanreotide, 1 mg -Brand name: Somatuline Depot	Master Precertification List For Health Care Providers, Pg 79 Original policy
J1931	Injection, laronidase, 0.1 mg	Master Precertification List For Health Care Providers, Pg 79 Original policy
J1932*	Injection, lanreotide, (cipla), 1 mg	Master Precertification List For Health Care Providers, Pg 79 Original policy
J1950*	Injection, leuprolide acetate (for depot suspension), per 3.75 mg	Master Precertification List For Health Care Providers, Pg 79 Original policy
J1951	Injection, leuprolide acetate for depot suspension (fensolvi), 0.25 mg	Master Precertification List For Health Care Providers, Pg 79 Original policy
J1952*	Leuprolide injectable, camcevi, 1 mg	Master Precertification List For Health Care Providers, Pg 79 Original policy
J1954*	Injection, leuprolide acetate for depot suspension (lutrate depot), 7.5 mg	Master Precertification List For Health Care Providers, Pg 79 Original policy
J1961	Injection, lenacapavir, 1 mg	Master Precertification List For Health Care Providers, Pg 79 Original policy
J2170	Injection, mecasermin, 1 mg	Master Precertification List For Health Care Providers, Pg 79 Original policy
J2182	Injection, mepolizumab, 1 mg	Master Precertification List For Health Care Providers, Pg 79 Original policy
J2267	Injection, mirikizumab-mrkz, 1 mg	Master Precertification List For Health Care Providers, Pg 79 Original policy
J2277	Injection, motixafortide, 0.25 mg	Master Precertification List For Health Care Providers, Pg 79 Original policy
J2323	Injection, natalizumab, 1 mg	Master Precertification List For Health Care Providers, Pg 79 Original policy
J2326	Injection, nusinersen, 0.1 mg	Master Precertification List For Health Care Providers, Pg 79 Original policy
J2327	Injection, risankizumab-rzaa, intravenous, 1 mg	Master Precertification List For Health Care Providers, Pg 80 Original policy
J2329	Injection, ublituximab-xiiy, 1mg	Master Precertification List For Health Care Providers, Pg 80 Original policy
J2350	Injection, ocrelizumab, 1 mg	Master Precertification List For Health Care Providers, Pg 80 Original policy
J2351	Injection, ocrelizumab, 1 mg and hyaluronidase-ocsq	Master Precertification List For Health Care Providers, Pg 80 Original policy
J2353*	Injection, octreotide, depot form for intramuscular injection, 1 mg	Master Precertification List For Health Care Providers, Pg 80 Original policy
J2354*	Injection, octreotide, non-depot form for subcutaneous or intravenous injection, 25 mcg	Master Precertification List For Health Care Providers, Pg 80 Original policy
J2356	Injection, tezepelumab-ekko, 1 mg	Master Precertification List For Health Care Providers, Pg 80 Original policy
J2357	Injection, omalizumab, 5 mg	Master Precertification List For Health Care Providers, Pg 80 Original policy
J2361	Injection, depemokimab-ulaa, 1 mg	Master Precertification List For Health Care Providers, Pg 80 Original policy
J2502	Injection, pasireotide long acting, 1 mg	Master Precertification List For Health Care Providers, Pg 80 Original policy
J2506*	Injection, pegfilgrastim, excludes biosimilar, 0.5 mg	Master Precertification List For Health Care Providers, Pg 80 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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