How to appeal a Cigna hiv prep & hiv treatment 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 hiv prep & hiv treatment

Cited policy: Cigna / Express Scripts HIV coverage policy + PrEP coverage policy

Tier placement; QL on PrEP refills; ACA §2713 mandate when properly coded.

How Cigna denies hiv prep & hiv treatment — and how to counter it

Where Cigna pushes back: 1) Tier copay applied to Descovy; 2) QL on PrEP (30-day only); 3) HBV testing not covered as ancillary.

Counter-arguments that hold up: ACA §2713 prohibits cost-sharing for any PrEP modality; FAQ Part 47 explicitly includes ancillary services (HIV/STI/HCV/HBV testing, creatinine/renal testing, pregnancy testing, PrEP-related visits). HHS FAQ Part 47: utilization management cannot unduly restrict access; 90-day supplies appropriate for stable patients.

What Cigna typically denies for hiv prep & hiv treatment

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

• Truvada PrEP (generic)
• Descovy PrEP
• Apretude LA PrEP
• Biktarvy
• Dovato
• Triumeq

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.