How to appeal a Cigna interventional radiology — ufe, pae, tips, y-90, tumor ablation, kyphoplasty 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 interventional radiology — ufe, pae, tips, y-90, tumor ablation, kyphoplasty

Cited policy: Cigna coverage policy Selective Internal Radiation Therapy / Radioembolization (Y-90)

BCLC-aligned HCC (typically BCLC B intermediate; selected BCLC A bridging to transplant or segmentectomy; selected BCLC C with portal vein invasion); unresectable colorectal liver metastases or selected NETs; performed at experienced center with multi-D tumor board.

How Cigna denies interventional radiology — ufe, pae, tips, y-90, tumor ablation, kyphoplasty — and how to counter it

Where Cigna pushes back: 1) BCLC stage 'wrong' for Y-90; 2) Tumor board not documented; 3) Lung shunt fraction not measured; 4) MELD / Child-Pugh too advanced.

Counter-arguments that hold up: Cite BCLC 2022 update (Reig J Hepatol 2022); LEGACY trial (Salem Hepatology 2021) for Y-90 segmentectomy; DOSISPHERE-01 (Garin Lancet Gastroenterol Hepatol 2021) for personalized dosimetry; PRECISION-V for DEB-TACE; SARAH / SIRveNIB / DOORWAY for advanced HCC. Document tumor board consensus, BCLC stage, Child-Pugh score, MELD, MAA scan with lung shunt fraction <20%, tumor-to-normal ratio, planned dose. AASLD HCC guidance (Heimbach Hepatology 2018). Distinguish glass (TheraSphere) from resin (SIR-Spheres) where relevant.

What Cigna typically denies for interventional radiology — ufe, pae, tips, y-90, tumor ablation, kyphoplasty

Across Cigna's commercial and Medicare books, denials cluster around a small number of patterns. For interventional radiology — ufe, pae, tips, y-90, tumor ablation, kyphoplasty, 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 interventional radiology — ufe, pae, tips, y-90, tumor ablation, kyphoplasty treatments most often flagged for prior auth, step therapy, or medical necessity review:

• UFE (uterine fibroid embolization)
• PAE (prostate artery embolization)
• TIPS
• Y-90 radioembolization
• TACE (HCC)
• Cryoablation

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.