Apligraf denied for missing prior authorization by Cigna?

Cigna's specific coverage criteria for apligraf 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 Apligraf

Apligraf is a bioengineered living skin substitute used for chronic wounds that have not responded to conventional care. Because it carries a higher unit cost than standard wound-care supplies, Cigna places it on a utilization-management list requiring prior authorization (PA) before the service is rendered. A denial for "prior-auth-required" means either the authorization was not obtained in advance or the PA request did not contain sufficient clinical documentation to meet Cigna's coverage criteria.

## Why This Is Appealable

If care was already provided without PA due to clinical urgency, or if the PA was submitted but denied, you have full appeal rights. The key is demonstrating that the clinical criteria Cigna uses to evaluate Apligraf requests — found in their published medical policy — were met at the time of service. Obtain Cigna's current medical policy for bioengineered skin substitutes and compare each criterion against the patient's chart.

## Federal Appeal Framework

• Internal appeal (Level 1): File within the deadline on your denial letter. Submit complete clinical records, not just a summary.
• Internal appeal (Level 2): If Cigna offers a second level, use it — each level builds the administrative record for external review.
• ACA §2719 external review: Available after exhausting internal appeals. An Independent Review Organization (IRO) reviews the clinical record de novo. The window is approximately four months from final internal denial. Expedited review is available for urgent situations.
• ERISA §503: For employer-sponsored plans, ensures a full-and-fair review with access to the criteria used in the denial.

## What to Gather

• Wound history with dates: A timeline of the wound's duration, size progression, and all treatments attempted, each with start/end dates and documented outcomes.
• Standard-of-care failure documentation: Chart notes, wound measurements, and photographs showing inadequate response to conventional wound care prior to Apligraf.
• Diagnosis confirmation: Physician or podiatrist notes confirming the wound type falls within Apligraf's cleared indication per the FDA labeling.
• Prescriber medical-necessity letter: A detailed letter tying the patient's clinical picture to each of Cigna's PA criteria by name.
• Applicable guideline reference: Reference to the relevant wound-care specialty society guideline supporting advanced skin-substitute therapy in this indication.

## Criteria-Mapping Structure

Download Cigna's medical policy for bioengineered skin substitutes. In your appeal, list every criterion verbatim, then provide the corresponding chart fact or document that satisfies it. If the PA was denied because a criterion was deemed unmet, address that criterion specifically with additional documentation.