How to appeal a Cigna genetic testing denial
ACA §2719 + ERISA §503 · 180-day window · 30-day decision
To appeal a Cigna genetic testing denial, file an internal appeal within 180 days of the date on the denial letter through Cigna's member or provider portal, under ACA §2719 + ERISA §503. Cigna returns standard decisions in 30 days; if it upholds the denial you can request an independent external review within 4 months.
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 genetic testing
Cited policy: Cigna coverage policy (Hereditary Cancer Susceptibility) + 0514 (Collateral) + 0518 (WES/WGS) + NIPT policy (delegated to eviCore)
NCCN for hereditary cancer; ACMG for WES (pediatric undiagnosed dz); NIPT for all pregnancies (updated 2022) for trisomy 13/18/21.
How Cigna denies genetic testing — and how to counter it
Where Cigna pushes back: 1) 'eviCore prior auth not obtained' (procedural — most common); 2) 'Tumor profiling — only FDA-approved tests in FDA-labeled indications'; 3) 'WGS experimental for adult-onset or non-acute indications'; 4) 'Microdeletion add-on to NIPT not covered' (22q11.2 etc.).
Counter-arguments that hold up: Submit eviCore prior auth retroactively with full clinical. For NIPT: ACOG #226 + SMFM consult series. For tumor NGS in advanced ca: CMS NCD 90.2 + MolDX LCD + NCCN biomarker compendium (NSCLC requires EGFR/ALK/ROS1/BRAF/MET/RET/KRAS/NTRK/HER2).
What Cigna typically denies for genetic testing
Across Cigna's commercial and Medicare books, denials cluster around a small number of patterns. For genetic testing, 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 genetic testing treatments most often flagged for prior auth, step therapy, or medical necessity review:
- Hereditary cancer panel
- BRCA1/2
- Lynch panel
- Cardiogenetic
- WES / WGS
- Carrier screening
How to submit the appeal to Cigna
- Read the denial letter — note the exact denial reason code and the appeal deadline (180 days from the date on the letter).
- 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.
- 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.
- 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.
Frequently asked questions
How long do I have to appeal a Cigna genetic testing denial?
Cigna allows 180 days from the date on the denial letter to file an internal appeal. Standard decisions come back within 30 days; expedited decisions for urgent care typically within 72 hours.
What's the fastest way to submit a Cigna appeal?
Members can submit through the Cigna member portal at https://my.cigna.com. Providers should use the provider portal at https://cignaforhcp.cigna.com. Faxed and mailed appeals are accepted but take longer.
What denials does Cigna most often issue for genetic testing?
For genetic testing, Cigna most often denies on: 1) 'eviCore prior auth not obtained' (procedural — most common); 2) 'Tumor profiling — only FDA-approved tests in FDA-labeled indications'; 3) 'WGS experimental for adult-onset or non-acute indications'; 4) 'Microdeletion add-on to NIPT not covered' (22q11.2 etc.). The strongest counters: Submit eviCore prior auth retroactively with full clinical. For NIPT: ACOG #226 + SMFM consult series. For tumor NGS in advanced ca: CMS NCD 90.2 + MolDX LCD + NCCN biomarker compendium (NSCLC requires EGFR/ALK/ROS1/BRAF/MET/RET/KRAS/NTRK/HER2).
What if Cigna denies the appeal too?
After an internal appeal denial you have the right to an external review by an independent reviewer (IRO) — request it within 4 months of the final internal denial.
Related appeal guides
Start your Genetic testing appeal
Upload your Cigna denial letter — DenialHelp drafts a physician-ready appeal in five minutes, aligned to ACA §2719 + ERISA §503.
Get started →Contact: hello@denialhelp.com