Anti Cd 20 Ocrevus denied for missing prior authorization by Cigna?

Cigna's specific coverage criteria for anti cd20 ocrevus 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 Ocrelizumab

Ocrelizumab (Ocrevus) is a high-cost specialty infusion drug for multiple sclerosis. Cigna, like most major insurers, places it on a tier of its formulary that requires prior authorization (PA) before every new course of therapy and often before renewals. A PA-required denial means the claim was submitted and processed before the authorization was in place — or the PA was requested but not yet approved. This is one of the most common and most routinely reversed denials for specialty MS therapies.

## Why This Denial Is Appealable

A PA-required denial is not a clinical judgment about whether the drug is appropriate for you — it is an administrative gate. If the underlying clinical criteria are met, the authorization must be granted. If a PA was submitted and denied on clinical grounds, that denial is separately appealable on the merits. If the claim was simply submitted without a PA, the fix is often to obtain the PA retroactively, which many Cigna plans allow within a defined window.

## Your Federal Appeal Rights

• Internal appeal: ACA §2719 and ERISA §503 guarantee a full-and-fair internal review. File within the deadline in your denial letter.
• External review: After exhausting internal appeals, an independent external review is available under ACA §2719, typically within approximately four months of final internal denial.
• Expedited track: Active infusion patients facing interruption of an ongoing treatment course should request expedited review immediately, as decisions are generally required within 72 hours.

## Documentation to Gather

1. Completed PA request and any prior PA approval history — show a documented pattern of authorized, effective treatment. 2. Neurologist's medical-necessity letter stating the diagnosis, disease course, and clinical rationale for ocrelizumab specifically. 3. Diagnosis confirmation — MRI reports and clinical notes establishing the MS diagnosis and classification. 4. Prior disease-modifying therapy history — a dated log of any therapies previously used, including start/stop dates and reasons for discontinuation or transition. 5. Cigna's PA criteria — obtain the current authorization criteria from Cigna's published coverage policy and confirm each criterion is addressed in the clinical documentation.

## Criteria-Mapping Approach

Obtain Cigna's written PA criteria for ocrelizumab. Create a table with each criterion in the left column. In the right column, cite the exact chart note, date, or lab report that satisfies it. Pay particular attention to any step-therapy or prior-treatment requirements listed in the PA criteria, and ensure the prescriber's letter explicitly addresses each one. A complete, criterion-by-criterion response reduces the chance of a second denial on a different technicality.

## Next Step

If a PA was never submitted, work with your infusion center or prescriber's office to submit one immediately and request retroactive authorization if available. If the PA was denied on clinical grounds, treat this as a medical-necessity appeal and build the documentation package described above.