Cigna prior authorization, page 39

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
J9206*	Injection, irinotecan, 20 mg	Master Precertification List For Health Care Providers, Pg 87 Original policy
J9207*	Injection, ixabepilone, 1 mg	Master Precertification List For Health Care Providers, Pg 87 Original policy
J9208*	Injection, ifosfamide, 1 gram	Master Precertification List For Health Care Providers, Pg 87 Original policy
J9210	Injection, emapalumab-lzsg, 1 mg	Master Precertification List For Health Care Providers, Pg 87 Original policy
J9211*	Injection, idarubicin hydrochloride, 5 mg	Master Precertification List For Health Care Providers, Pg 87 Original policy
J9213	Injection, interferon, alfa-2a, recombinant, 3 million units	Master Precertification List For Health Care Providers, Pg 87 Original policy
J9214*	Injection, interferon, alfa-2b, recombinant, 1 million units	Master Precertification List For Health Care Providers, Pg 87 Original policy
J9215	Injection, interferon, alfa-n3, (human leukocyte derived), 250,000 iu	Master Precertification List For Health Care Providers, Pg 87 Original policy
J9216*	Injection, interferon, gamma 1-b, 3 million units	Master Precertification List For Health Care Providers, Pg 87 Original policy
J9217*	Leuprolide acetate (for depot suspension), 7.5 mg	Master Precertification List For Health Care Providers, Pg 87 Original policy
J9223*	Injection, lurbinectedin, 0.1 mg	Master Precertification List For Health Care Providers, Pg 87 Original policy
J9225*	Histrelin implant (vantas), 50 mg	Master Precertification List For Health Care Providers, Pg 87 Original policy
J9226	Histrelin implant (supprelin la), 50 mg	Master Precertification List For Health Care Providers, Pg 87 Original policy
J9227*	Injection, isatuximab-irfc, 10 mg	Master Precertification List For Health Care Providers, Pg 87 Original policy
J9228*	Injection, ipilimumab, 1 mg	Master Precertification List For Health Care Providers, Pg 87 Original policy
J9229*	Injection, inotuzumab ozogamicin, 0.1 mg	Master Precertification List For Health Care Providers, Pg 87 Original policy
J9230*	Injection, mechlorethamine hydrochloride, (nitrogen mustard), 10 mg	Master Precertification List For Health Care Providers, Pg 87 Original policy
J9232*	Injection, docetaxel (hospira), not therapeutically equivalent to j9171, 1 mg	Master Precertification List For Health Care Providers, Pg 87 Original policy
J9245*	Injection, melphalan hydrochloride, not otherwise specified, 50 mg	Master Precertification List For Health Care Providers, Pg 87 Original policy
J9246*	Injection, melphalan (evomela), 1 mg	Master Precertification List For Health Care Providers, Pg 87 Original policy
J9248*	Injection, melphalan (hepzato), 1 mg	Master Precertification List For Health Care Providers, Pg 87 Original policy
J9249*	Injection, melphalan (apotex), 1 mg	Master Precertification List For Health Care Providers, Pg 87 Original policy
J9256	Injection, nipocalimab-aahu, 3 mg	Master Precertification List For Health Care Providers, Pg 87 Original policy
J9261*	Injection, nelarabine, 50 mg	Master Precertification List For Health Care Providers, Pg 87 Original policy
J9262*	Injection, omacetaxine mepesuccinate, 0.01 mg	Master Precertification List For Health Care Providers, Pg 87 Original policy
J9263*	Injection, oxaliplatin, 0.5 mg	Master Precertification List For Health Care Providers, Pg 87 Original policy
J9264*	Injection, paclitaxel protein-bound particles, 1 mg	Master Precertification List For Health Care Providers, Pg 87 Original policy
J9266*	Injection, pegaspargase, per single dose vial	Master Precertification List For Health Care Providers, Pg 87 Original policy
J9267*	Injection, paclitaxel, 1 mg	Master Precertification List For Health Care Providers, Pg 87 Original policy
J9268*	Injection, pentostatin, 10 mg	Master Precertification List For Health Care Providers, Pg 88 Original policy
J9269*	Injection, tagraxofusp-erzs, 10 micrograms	Master Precertification List For Health Care Providers, Pg 88 Original policy
J9271*	Injection, pembrolizumab, 1 mg	Master Precertification List For Health Care Providers, Pg 88 Original policy
J9272*	Injection, dostarlimab-gxly, 10 mg	Master Precertification List For Health Care Providers, Pg 88 Original policy
J9273*	Injection, tisotumab vedotin-tftv, 1 mg	Master Precertification List For Health Care Providers, Pg 88 Original policy
J9274*	Injection, tebentafusp-tebn, 1 microgram	Master Precertification List For Health Care Providers, Pg 88 Original policy
J9275*	Injection, cosibelimab-ipdl, 2 mg	Master Precertification List For Health Care Providers, Pg 88 Original policy
J9276*	Injection, zanidatamab-hrii, 2 mg	Master Precertification List For Health Care Providers, Pg 88 Original policy
J9277*	Injection, pembrolizumab, 1 mg and berahyaluronidase alfa-pmph	Master Precertification List For Health Care Providers, Pg 88 Original policy
J9278*	Injection, carboplatin (avyxa), 1 mg	Master Precertification List For Health Care Providers, Pg 88 Original policy
J9280*	Injection, mitomycin, 5 mg	Master Precertification List For Health Care Providers, Pg 88 Original policy
J9281*	Mitomycin pyelocalyceal instillation, 1 mg	Master Precertification List For Health Care Providers, Pg 88 Original policy
J9282*	Mitomycin, intravesical instillation, 1 mg	Master Precertification List For Health Care Providers, Pg 88 Original policy
J9285*	Injection, olaratumab, 10 mg	Master Precertification List For Health Care Providers, Pg 88 Original policy
J9286*	Injection, glofitamab-gxbm, 2.5 mg	Master Precertification List For Health Care Providers, Pg 88 Original policy
J9289*	Injection, nivolumab, 2 mg and hyaluronidase-nvhy	Master Precertification List For Health Care Providers, Pg 88 Original policy
J9292*	Injection, pemetrexed (avyxa), not therapeutically equivalent to J9305, 10 mg	Master Precertification List For Health Care Providers, Pg 88 Original policy
J9293*	Injection, mitoxantrone hydrochloride, per 5 mg	Master Precertification List For Health Care Providers, Pg 88 Original policy
J9294*	Injection, pemetrexed (hospira), not therapeutically equivalent to J9305, 10 mg	Master Precertification List For Health Care Providers, Pg 88 Original policy
J9295*	Injection, necitumumab, 1 mg	Master Precertification List For Health Care Providers, Pg 88 Original policy
J9296*	Injection, pemetrexed (accord), not therapeutically equivalent to J9305, 10 mg	Master Precertification List For Health Care Providers, Pg 88 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.