The Cigna HealthCare Prior Authorization Form for Intravenous Immune Globulin (IVIG) is required before any provider can administer IVIG therapy under Cigna plans. The form is divided into sections covering provider contact details, patient demographics, the specific IVIG brand requested, dose in grams per kilogram of body weight, and the planned infusion schedule.
The clinical documentation section requires the patient's primary or secondary immunodeficiency diagnosis along with ICD-10 codes. Qualifying conditions include primary humoral immunodeficiency diseases, common variable immunodeficiency (CVID), X-linked agammaglobulinemia, chronic lymphocytic leukemia (CLL), acquired hypogammaglobulinemia, and Kawasaki disease. Neurological applications (Guillain-Barre syndrome, multifocal motor neuropathy), hematological conditions (immune thrombocytopenic purpura), and rheumatological disorders are also covered under the form's clinical criteria.
Providers must attach recent immunoglobulin (IgG) serum level results and vaccine response data to support the authorization request. For reauthorization of ongoing IVIG therapy, the form requires documentation of the patient's clinical response to prior treatment cycles and updated laboratory values. Any incomplete or missing section may delay processing or result in an adverse determination. Cigna provides an expedited review path for urgent clinical cases that cannot wait for the standard 5 to 7 business day review window.
| Question | Answer |
|---|---|
| Form Name | Cigna Ivig Form |
| Form Length | 5 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 1 min 15 sec |
| Other names | cigna retro authorization form, cigna medicare part b prior authorization, cigna healthcare prior ivig form, cigna ivig form |