Anifrolumab denied for missing prior authorization by Cigna?

Cigna's specific coverage criteria for anifrolumab are defined in its own published medical/coverage policy and the FDA-approved prescribing label. A successful appeal documents that your medical records satisfy each criterion those sources list — confirmed diagnosis, any required prior treatments (with dates and outcomes), and clinical severity. If the exact criteria weren't included with your denial, request them in writing; your appeal then maps each requirement to the matching fact in your chart.

## Why Cigna Requires Prior Authorization for Anifrolumab

Prior authorization (PA) for anifrolumab is Cigna's standard administrative gatekeeping process for high-cost specialty biologics. The plan requires prospective clinical review before it will approve coverage. A "prior-auth required" denial typically means either no PA was submitted before the prescription was dispensed, or a submitted PA was denied because the supporting documentation did not satisfy Cigna's published clinical criteria. Both scenarios are recoverable.

## Why This Denial Is Appealable

If the PA was denied on clinical grounds, that decision is subject to internal appeal and, if necessary, independent external review. Cigna must apply its criteria consistently and reasonably. Where the clinical record documents a patient who meets the criteria in Cigna's own published policy, a clinical PA denial is routinely overturned on appeal. If no PA was submitted and the drug was dispensed in an emergency or urgent situation, a retroactive PA exception may also be available.

## Your Federal Appeal Rights

• Internal appeal (ERISA §503 / ACA §2719): A denied PA is an adverse benefit determination. You have the right to a full-and-fair review. Non-urgent internal appeals must be decided within 60 days; urgent appeals within 72 hours.
• External review: After exhausting internal appeals, independent external review is available under ACA §2719. File within approximately four months of the final internal denial. An independent reviewer — not Cigna — makes the binding decision.
• Expedited PA: For ongoing treatment where interruption poses health risk, request expedited PA reconsideration simultaneously with the internal appeal.

## Documentation to Gather

1. Diagnosis confirmation — rheumatologist notes, ANA and specific antibody panels, ACR/EULAR classification criteria documentation confirming moderate-to-severe SLE. 2. Disease-activity severity evidence — validated disease-activity scores in the chart, documentation of organ involvement or flare history with dates. 3. Prior treatment history — complete dated record of prior SLE medications trialed, duration of each, and outcome (inadequate response, intolerance, or prescriber-documented reason for discontinuation). 4. Cigna's PA clinical criteria — obtain the current prior-authorization clinical policy from Cigna's provider portal. Map every listed criterion to a chart entry in your appeal submission. 5. Prescriber medical-necessity letter — from the treating rheumatologist, explicitly addressing each PA criterion and explaining the clinical rationale for anifrolumab at this time. 6. FDA prescribing label — confirm the indication, appropriate patient population, and recommended use per the label to demonstrate on-label use.

## Criteria-Mapping Structure

Create a numbered list in your appeal letter that mirrors Cigna's PA criteria list exactly, in order. For each criterion, quote it verbatim, then provide the specific chart date and finding that satisfies it. Attach supporting documents as numbered exhibits corresponding to each criterion. This makes it easy for the reviewer to approve each item individually and difficult to issue a blanket denial without addressing the evidence you have provided.