How to appeal a Cigna pulmonary hypertension 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 pulmonary hypertension

Cited policy: Cigna Tyvaso (Inhaled Treprostinil) PA — PAH and PH-ILD (Policy #coverage policy)

PAH: WHO Group 1, FC III–IV, RHC-confirmed, on background ERA and/or PDE5i. PH-ILD: HRCT-confirmed ILD, RHC mPAP ≥25 mmHg, PVR ≥3 WU, FC II–IV, age ≥18. Tyvaso DPI alternative device for ages ≥18. Reauth 6 mo on 6MWD or FC improvement.

How Cigna denies pulmonary hypertension — and how to counter it

Where Cigna pushes back: 1) PH-ILD (Group 3) not a covered indication; 2) Try selexipag oral first; 3) Insufficient ILD severity.

Counter-arguments that hold up: Tyvaso inhaled FDA-approved Mar 31, 2021 specifically for PH associated with ILD (WHO Group 3) — first FDA-approved therapy ever for PH-ILD. INCREASE Waxman NEJM 2021;384(4):325-334 — Phase 3 n=326, primary endpoint 6MWD +21.1 m vs placebo at 16 wk (p<0.001), reduction in NT-proBNP and clinical worsening. Tyvaso DPI device extension Jun 2022 (BREEZE Pulm Circ 2022). Selexipag (GRIPHON) studied in WHO Group 1 only — no Group 3 indication.

What Cigna typically denies for pulmonary hypertension

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

• Winrevair (sotatercept)
• Opsumit (macitentan)
• Letairis (ambrisentan)
• Tracleer (bosentan)
• Adcirca/Alyq (tadalafil)
• Revatio (sildenafil)

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.