How to appeal a Cigna growth hormone replacement therapy 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 growth hormone replacement therapy

Cited policy: Cigna Norditropin / Daily Somatropin PA — Pediatric & Adult GHD, Turner, SGA, PWS, Noonan, SHOX, CKD

Pediatric GHD: TWO provocative tests peak <10 ng/mL + IGF-1 SDS low + auxologic criteria (height SDS ≤-2.25 OR HV SDS ≤-1 with height SDS ≤-2). Turner: karyotype-confirmed regardless of GH peak. SGA: failure to catch by age 2-4 with height SDS ≤-2.5. PWS: genetic confirmation (methylation / FISH del15q). Noonan: PTPN11 / RAS-pathway confirmation. CKD: stage III-V pre-transplant with growth failure. Adult GHD: ITT or glucagon or macimorelin (Macrilen). Endocrinologist Rx. Reauth annually with HV / IGF-1 / QoL response.

How Cigna denies growth hormone replacement therapy — and how to counter it

Where Cigna pushes back: 1) Single stim test inadequate; 2) Turner / Noonan / SHOX without documented GHD; 3) Adult GHD not life-threatening; 4) SGA child still in catch-up phase; 5) Bone age must catch up before reauth.

Counter-arguments that hold up: Endocrine Society 2016 + AACE 2019 — TWO provocative tests gold standard; ITT remains gold; if contraindicated (seizure / cardiac / age <3 yr) use arginine±GHRH / glucagon / clonidine / macimorelin (FDA Dec 20 2017 for adult GHD diagnosis). Turner / Noonan / SHOX are FDA-approved indications REGARDLESS of GH peak per ESPE/PES/ES Cincinnati 2017 (Gravholt EJE 2017) — functional GH resistance + SHOX haploinsufficiency. Stephure JCEM 2005 — GH adds ~7 cm adult height in Turner. Adult GHD per AACE 2019: dyslipidemia, ↓lean mass, ↑visceral fat, ↓BMD, impaired QoL (AGHDA), HypoCCS / KIMS mortality. SGA failure-to-catch by age 2-4 with SDS ≤-2.5 is FDA indication. Bone-age catch-up only required for ISS initiation — GHD / Turner / SGA / PWS continue per IGF-1 + Tanner + HV.

What Cigna typically denies for growth hormone replacement therapy

Across Cigna's commercial and Medicare books, denials cluster around a small number of patterns. For growth hormone replacement therapy, 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 growth hormone replacement therapy treatments most often flagged for prior auth, step therapy, or medical necessity review:

• Norditropin (daily)
• Genotropin (daily)
• Humatrope (daily)
• Saizen (daily)
• Omnitrope (biosimilar daily)
• Nutropin AQ (daily)

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.