Cigna prior authorization, page 42

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
M0224	Intravenous infusion, pemivibart, for the pre-exposure prophylaxis only, for certain adults and adolescents (12 years of age and older weighing at least 40 kg) with no known sars-cov-2 exposure, who either have moderate-to-severe immune compromise due to a medical condition or receipt of immunosuppressive medications or treatments, includes infusion and post administration monitoring	Master Precertification List For Health Care Providers, Pg 92 Original policy
M0231	Intravenous infusion, tocilizumabbavi, for hospitalized adult patients with covid-19 who are receiving systemic corticosteroids and require supplemental oxygen, non-invasive or invasive mechanical ventilation, or extracorporeal membrane oxygenation only, includes infusion and post administration monitoring, first dose	Master Precertification List For Health Care Providers, Pg 92 Original policy
M0232	Intravenous infusion, tocilizumabbavi, for hospitalized adult patients with covid-19 who are receiving systemic corticosteroids and require supplemental oxygen, non-invasive or invasive mechanical ventilation, or extracorporeal membrane oxygenation only, includes infusion and post administration monitoring, second dose	Master Precertification List For Health Care Providers, Pg 92 Original policy
M0233	Intravenous infusion, tocilizumab aazg, for hospitalized adult patients with covid-19 who are receiving systemic corticosteroids and require supplemental oxygen, non-invasive or invasive mechanical ventilation, or extracorporeal membrane oxygenation (ecmo) only, includes infusion and post administration monitoring, first dose	Master Precertification List For Health Care Providers, Pg 92 Original policy
M0234	Intravenous infusion, tocilizumab aazg, for hospitalized adult patients with covid-19 who are receiving systemic corticosteroids and require supplemental oxygen, non-invasive or invasive mechanical ventilation, or extracorporeal membrane oxygenation (ecmo) only, includes infusion and post administration monitoring, second dose	Master Precertification List For Health Care Providers, Pg 92 Original policy
M0235	Intravenous infusion, monoclonal antibody products with an indication for post-exposure prophylaxis or treatment of COVID-19, for hospitalized adults and/or pediatric patients who are receiving systemic corticosteroids and require supplemental oxygen, non-invasive or invasive mechanical ventilation, or extracorporeal membrane oxygenation (ecmo) only, includes infusion and post administration monitoring, not otherwise classified, first dose	Master Precertification List For Health Care Providers, Pg 92 Original policy
M0236	Intravenous infusion, monoclonal antibody products with an indication for post-exposure prophylaxis or treatment of COVID-19, for hospitalized adults and/or pediatric patients who are receiving systemic corticosteroids and require supplemental oxygen, non-invasive or invasive mechanical ventilation, or extracorporeal membrane oxygenation (ecmo) only, includes infusion and post administration monitoring, not otherwise classified, second dose	Master Precertification List For Health Care Providers, Pg 92 Original policy
M0237	Intravenous infusion, tocilizumab-anoh, for hospitalized adult patients with covid-19 who are receiving systemic corticosteroids and require supplemental oxygen, non-invasive or invasive mechanical ventilation, or extracorporeal membrane oxygenation (ecmo) only, includes infusion and post administration monitoring, first dose	Master Precertification List For Health Care Providers, Pg 93 Original policy
M0238	Intravenous infusion, tocilizumab-anoh, for hospitalized adult patients with covid-19 who are receiving systemic corticosteroids and require supplemental oxygen, non-invasive or invasive mechanical ventilation, or extracorporeal membrane oxygenation (ecmo) only, includes infusion and post administration monitoring, second dose	Master Precertification List For Health Care Providers, Pg 93 Original policy
Q0138	Injection, ferumoxytol, for treatment of iron deficiency anemia, 1 mg (non-esrd use)	Master Precertification List For Health Care Providers, Pg 93 Original policy
Q0224	Injection, pemivibart, for the pre-exposure prophylaxis only, for certain adults and adolescents (12 years of age and older weighing at least 40 kg) with no known sars-cov-2 exposure, and who either have moderate- to-severe immune compromise due to a medical condition or receipt of immunosuppressive medications or treatments, and are unlikely to mount an adequate immune response to COVID-19 vaccination, 4500 mg	Master Precertification List For Health Care Providers, Pg 93 Original policy
Q0234	Injection, tocilizumab-bavi, for hospitalized adult patients with covid-19 who are receiving systemic corticosteroids and require supplemental oxygen, non-invasive or invasive mechanical ventilation, or extracorporeal membrane oxygenation only, 1 mg	Master Precertification List For Health Care Providers, Pg 93 Original policy
Q0235	Injection, monoclonal antibody products with an indication for post- exposure prophylaxis or treatment of COVID-19, for hospitalized adults and/or pediatric patients who are receiving systemic corticosteroids and require supplemental oxygen, non-invasive or invasive mechanical ventilation, or extracorporeal membrane oxygenation (ecmo) only, not otherwise classified, 1 mg	Master Precertification List For Health Care Providers, Pg 93 Original policy
Q0237	Injection, tocilizumab-anoh, for hospitalized adult patients with covid-19 who are receiving systemic corticosteroids and require supplemental oxygen, non-invasive or invasive mechanical ventilation, or extracorporeal membrane oxygenation (ecmo) only, 1 mg	Master Precertification List For Health Care Providers, Pg 93 Original policy
Q0238	Injection, tocilizumab-aazg, for hospitalized adult patients with covid-19 who are receiving systemic corticosteroids and require supplemental oxygen, non-invasive or invasive mechanical ventilation, or extracorporeal membrane oxygenation (ecmo) only, 1 mg	Master Precertification List For Health Care Providers, Pg 93 Original policy
Q2026*	Injection, radiesse, 0.1 ml	Master Precertification List For Health Care Providers, Pg 93 Original policy
Q2028*	Injection, sculptra, 0.5 mg	Master Precertification List For Health Care Providers, Pg 93 Original policy
Q2041	Axicabtagene ciloleucel, up to 200 million autologous anti-cd19 car positive viable t cells, including leukapheresis and dose preparation procedures, per therapeutic dose	Master Precertification List For Health Care Providers, Pg 93 Original policy
Q2042	Tisagenlecleucel, up to 600 million car-positive viable t cells, including leukapheresis and dose preparation procedures, per therapeutic dose	Master Precertification List For Health Care Providers, Pg 93 Original policy
Q2043*	Sipuleucel-t, minimum of 50 million autologous cd54+ cells activated with pap-gm-csf, including leukapheresis and all other preparatory procedures, per infusion	Master Precertification List For Health Care Providers, Pg 93 Original policy
Q2050*	Injection, doxorubicin hydrochloride, liposomal, not otherwise specified, 10 mg	Master Precertification List For Health Care Providers, Pg 93 Original policy
Q2053	Brexucabtagene autoleucel, up to 200 million autologous anti-cd19 car positive viable t cells, including leukapheresis and dose preparation procedures, per therapeutic dose	Master Precertification List For Health Care Providers, Pg 93 Original policy
Q2054	Lisocabtagene maraleucel, up to 110 million autologous anti-cd19 car- positive viable t cells, including leukapheresis and dose preparation procedures, per therapeutic dose	Master Precertification List For Health Care Providers, Pg 93 Original policy
Q2055	Idecabtagene vicleucel, up to 510 million autologous b-cell maturation antigen (bcma) directed car-positive t cells, including leukapheresis and dose preparation procedures, per therapeutic dose	Master Precertification List For Health Care Providers, Pg 94 Original policy
Q2056	Ciltacabtagene autoleucel, up to 100 million autologous b-cell maturation antigen (bcma) directed car-positive t cells, including leukapheresis and dose preparation procedures, per therapeutic dose	Master Precertification List For Health Care Providers, Pg 94 Original policy
Q2057	Afamitresgene autoleucel, including leukapheresis and dose preparation procedures, per therapeutic dose	Master Precertification List For Health Care Providers, Pg 94 Original policy
Q2058	Obecabtagene autoleucel, up to 400 million cd19 car-positive viable t cells, including leukapheresis and dose preparation procedures, per therapeutic dose	Master Precertification List For Health Care Providers, Pg 94 Original policy
Q3027	Injection, interferon beta-1a, 1 mcg for intramuscular use	Master Precertification List For Health Care Providers, Pg 94 Original policy
Q3028	Injection, interferon beta-1a, 1 mcg for subcutaneous use	Master Precertification List For Health Care Providers, Pg 94 Original policy
Q4074	Iloprost, inhalation solution, fda-approved final product, non- compounded, administered through dme, unit dose form, up to 20 micrograms	Master Precertification List For Health Care Providers, Pg 94 Original policy
Q4081	Injection, epoetin alfa, 100 units (for esrd on dialysis)	Master Precertification List For Health Care Providers, Pg 94 Original policy
Q4102*	Oasis wound matrix, per square centimeter	Master Precertification List For Health Care Providers, Pg 94 Original policy
Q4103*	Oasis burn matrix, per square centimeter	Master Precertification List For Health Care Providers, Pg 94 Original policy
Q4113*	Graftjacket xpress, injectable, 1 cc	Master Precertification List For Health Care Providers, Pg 94 Original policy
Q4114*	Integra flowable wound matrix, injectable, 1 cc	Master Precertification List For Health Care Providers, Pg 94 Original policy
Q4118*	Matristem micromatrix, 1 mg	Master Precertification List For Health Care Providers, Pg 94 Original policy
Q4122*	Dermacell, dermacell awm or dermacell awm porous, per square centimeter	Master Precertification List For Health Care Providers, Pg 94 Original policy
Q4124*	Oasis ultra tri-layer wound matrix, per square centimeter	Master Precertification List For Health Care Providers, Pg 94 Original policy
Q4125*	Arthroflex, per square centimeter	Master Precertification List For Health Care Providers, Pg 94 Original policy
Q4126*	Memoderm, dermaspan, tranzgraft or integuply, per square centimeter	Master Precertification List For Health Care Providers, Pg 94 Original policy
Q4128*	Flex hd, or allopatch hd, per square centimeter	Master Precertification List For Health Care Providers, Pg 94 Original policy
Q4130*	Strattice tm, per square centimeter	Master Precertification List For Health Care Providers, Pg 94 Original policy
Q4132*	Grafix core and grafixpl core, per square centimeter	Master Precertification List For Health Care Providers, Pg 94 Original policy
Q4133*	Grafix prime, grafixpl prime, stravix and stravixpl, per square centimeter	Master Precertification List For Health Care Providers, Pg 94 Original policy
Q4137*	Amnioexcel, amnioexcel plus or biodexcel, per square centimeter	Master Precertification List For Health Care Providers, Pg 94 Original policy
Q4138*	Biodfence dryflex, per square centimeter	Master Precertification List For Health Care Providers, Pg 94 Original policy
Q4139*	Amniomatrix or biodmatrix, injectable, 1 cc	Master Precertification List For Health Care Providers, Pg 94 Original policy
Q4140*	Biodfence, per square centimeter	Master Precertification List For Health Care Providers, Pg 94 Original policy
Q4148*	Neox cord 1k, neox cord rt, or clarix cord 1k, per square centimeter	Master Precertification List For Health Care Providers, Pg 94 Original policy
Q4150*	Allowrap ds or dry, per square centimeter	Master Precertification List For Health Care Providers, Pg 94 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.