How to appeal a Cigna endocrine (non-diabetes) denial

The framework that applies to your appeal

Federal law gives you the right to a full and fair internal appeal, then an external review by an independent third party.

Cigna-specific note: Sold its Medicaid Advantage book to HCSC in 2023. Express Scripts (PBM) is Cigna-owned. Frequent class-action litigation around mental health parity.

What Cigna's policy requires for endocrine (non-diabetes)

Cited policy: Cigna Coverage Policy on Osilodrostat (Isturisa) — Cushing's

Endogenous Cushing's syndrome (2 of 3 biochemical tests) not amenable to surgery or post-surgical persistence. Endocrinologist Rx.

How Cigna denies endocrine (non-diabetes) — and how to counter it

Where Cigna pushes back: 1) Surgery not attempted; 2) Ketoconazole not trialed first; 3) Step therapy.

Counter-arguments that hold up: Document non-surgical candidate (ectopic ACTH, occult source, surgical failure, comorbidity) — Endocrine Society 2015 supports medical therapy as primary. Cite ketoconazole hepatotoxicity contraindication, drug-drug interactions, or prior failure. LINC 3 / LOGICS support direct use.

What Cigna typically denies for endocrine (non-diabetes)

Across Cigna's commercial and Medicare books, denials cluster around a small number of patterns. For endocrine (non-diabetes), expect:

• Mental health parity violations
• Step therapy
• Specialty drug prior auth
• OON balance billing disputes

Treatments most often denied in this category

These are the endocrine (non-diabetes) treatments most often flagged for prior auth, step therapy, or medical necessity review:

• TRT
• Tepezza (TED)
• Crenessity (CAH)
• Isturisa (Cushing's)
• Recorlev
• Mycapssa

How to submit the appeal to Cigna

1. Read the denial letter — note the exact denial reason code and the appeal deadline (180 days from the date on the letter).
2. Gather supporting documentation: physician letter of medical necessity, relevant clinical notes, peer-reviewed citations supporting the treatment for your indication, and the policy or coverage document Cigna cited in the denial.
3. File the appeal through Cigna's portal (members: https://my.cigna.com ; providers: https://cignaforhcp.cigna.com). Standard decision returns within 30 days; expedited urgent appeals return within 72 hours.
4. If denied again, request external review by an independent reviewer within 4 months of the final internal denial. In CT, the state insurance department coordinates external review for fully-insured plans; ERISA self-funded plans use a federal external review through DOL/EBSA.

Clinician or prior-auth team handling this on the practice side? See Cigna's prior-authorization criteria by drug: Cigna PA criteria on ApprovalHelp.