Cigna prior authorization, page 36

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
J3404	Injection, zopapogene imadenovec-drba suspension, per therapeutic dose	Master Precertification List For Health Care Providers, Pg 82 Original policy
J3405	Injection, onasemnogene abeparvovecbrve, per treatment	Master Precertification List For Health Care Providers, Pg 82 Original policy
J3406	Injection, omidubicel-onlv, per therapeutic dose	Master Precertification List For Health Care Providers, Pg 82 Original policy
J3490*	Unclassified drugs	Master Precertification List For Health Care Providers, Pg 82 Original policy
J3520	Edetate disodium, per 150 mg	Master Precertification List For Health Care Providers, Pg 82 Original policy
J3590*	Unclassified biologics	Master Precertification List For Health Care Providers, Pg 82 Original policy
J3591	Unclassified drug or biological used for esrd on dialysis	Master Precertification List For Health Care Providers, Pg 82 Original policy
J7170	Injection, emicizumab-kxwh, 0.5 mg	Master Precertification List For Health Care Providers, Pg 82 Original policy
J7171	Injection, adamts13, recombinant-krhn, 10 iu	Master Precertification List For Health Care Providers, Pg 82 Original policy
J7172	Injection, marstacimab-hncq, 0.5 mg	Master Precertification List For Health Care Providers, Pg 82 Original policy
J7173	Injection, concizumab-mtci, 0.5 mg	Master Precertification List For Health Care Providers, Pg 82 Original policy
J7174	Injection, fitusiran, 0.04 mg	Master Precertification List For Health Care Providers, Pg 82 Original policy
J7175	Injection, factor x, (human), 1 i.u.	Master Precertification List For Health Care Providers, Pg 82 Original policy
J7176	Injection, human fibrinogen - chmt (fesilty), 1mg	Master Precertification List For Health Care Providers, Pg 82 Original policy
J7177	Injection, human fibrinogen concentrate (fibryga), 1 mg	Master Precertification List For Health Care Providers, Pg 82 Original policy
J7178	Injection, human fibrinogen concentrate, not otherwise specified, 1 mg	Master Precertification List For Health Care Providers, Pg 82 Original policy
J7179	Injection, von willebrand factor (recombinant), (vonvendi), 1 i.u. vwf:rco	Master Precertification List For Health Care Providers, Pg 82 Original policy
J7180	Injection, factor xiii (antihemophilic factor, human), 1 i.u.	Master Precertification List For Health Care Providers, Pg 82 Original policy
J7181	Injection, factor xiii a-subunit, (recombinant), per iu	Master Precertification List For Health Care Providers, Pg 82 Original policy
J7182	Injection, factor viii, (antihemophilic factor, recombinant), (novoeight), per iu	Master Precertification List For Health Care Providers, Pg 82 Original policy
J7183	Injection, von willebrand factor complex (human), wilate, 1 i.u. vwf:rco	Master Precertification List For Health Care Providers, Pg 82 Original policy
J7185	Injection, factor viii (antihemophilic factor, recombinant) (xyntha), per i.u.	Master Precertification List For Health Care Providers, Pg 82 Original policy
J7186	Injection, antihemophilic factor viii/von willebrand factor complex (human), per factor viii i.u.	Master Precertification List For Health Care Providers, Pg 82 Original policy
J7187	Injection, von willebrand factor complex (humate-p), per iu vwf:rco	Master Precertification List For Health Care Providers, Pg 82 Original policy
J7188	Injection, factor viii (antihemophilic factor, recombinant), (obizur), per i.u.	Master Precertification List For Health Care Providers, Pg 82 Original policy
J7189	Factor viia (antihemophilic factor, recombinant), (novoseven rt), 1 microgram	Master Precertification List For Health Care Providers, Pg 82 Original policy
J7190	Factor viii (antihemophilic factor, human) per i.u.	Master Precertification List For Health Care Providers, Pg 82 Original policy
J7191	Factor viii (antihemophilic factor (porcine)), per i.u.	Master Precertification List For Health Care Providers, Pg 82 Original policy
J7192	Factor viii (antihemophilic factor, recombinant) per i.u., not otherwise specified	Master Precertification List For Health Care Providers, Pg 82 Original policy
J7193	Factor ix (antihemophilic factor, purified, non-recombinant) per i.u.	Master Precertification List For Health Care Providers, Pg 82 Original policy
J7194	Factor ix, complex, per i.u.	Master Precertification List For Health Care Providers, Pg 82 Original policy
J7195	Injection, factor ix (antihemophilic factor, recombinant) per iu, not otherwise specified	Master Precertification List For Health Care Providers, Pg 83 Original policy
J7196	Injection, antithrombin recombinant, 50 i.u.	Master Precertification List For Health Care Providers, Pg 83 Original policy
J7197	Antithrombin iii (human), per i.u.	Master Precertification List For Health Care Providers, Pg 83 Original policy
J7198	Anti-inhibitor, per i.u.	Master Precertification List For Health Care Providers, Pg 83 Original policy
J7199	Hemophilia clotting factor, not otherwise classified	Master Precertification List For Health Care Providers, Pg 83 Original policy
J7200	Injection, factor ix, (antihemophilic factor, recombinant), rixubis, per iu	Master Precertification List For Health Care Providers, Pg 83 Original policy
J7201	Injection, factor ix, fc fusion protein, (recombinant), alprolix, 1 i.u.	Master Precertification List For Health Care Providers, Pg 83 Original policy
J7202	Injection, factor ix, albumin fusion protein, (recombinant), idelvion, 1 i.u.	Master Precertification List For Health Care Providers, Pg 83 Original policy
J7203	Injection factor ix, (antihemophilic factor, recombinant), glycopegylated, (rebinyn), 1 iu	Master Precertification List For Health Care Providers, Pg 83 Original policy
J7204	Injection, factor viii, antihemophilic factor (recombinant), (esperoct), glycopegylated-exei, per iu	Master Precertification List For Health Care Providers, Pg 83 Original policy
J7205	Injection, factor viii fc fusion protein (recombinant), per iu	Master Precertification List For Health Care Providers, Pg 83 Original policy
J7207	Injection, factor viii, (antihemophilic factor, recombinant), pegylated, 1 i.u.	Master Precertification List For Health Care Providers, Pg 83 Original policy
J7208	Injection, factor viii, (antihemophilic factor, recombinant), pegylated- aucl, (jivi), 1 i.u.	Master Precertification List For Health Care Providers, Pg 83 Original policy
J7209	Injection, factor viii, (antihemophilic factor, recombinant), (nuwiq), 1 i.u.	Master Precertification List For Health Care Providers, Pg 83 Original policy
J7210	Injection, factor viii, (antihemophilic factor, recombinant), (afstyla), 1 i.u.	Master Precertification List For Health Care Providers, Pg 83 Original policy
J7211	Injection, factor viii, (antihemophilic factor, recombinant), (kovaltry), 1 i.u.	Master Precertification List For Health Care Providers, Pg 83 Original policy
J7212	Factor viia (antihemophilic factor, recombinant)-jncw (sevenfact), 1 microgram	Master Precertification List For Health Care Providers, Pg 83 Original policy
J7213	Injection, coagulation factor ix (recombinant), ixinity, 1 i.u.	Master Precertification List For Health Care Providers, Pg 83 Original policy
J7214	Injection, factor viii/von willebrand factor complex, recombinant (altuviiio), per factor viii i.u.	Master Precertification List For Health Care Providers, Pg 83 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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