Breyanzi denied as duplicate or overlapping therapy by Cigna?

Cigna's specific coverage criteria for breyanzi 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 Denied Breyanzi: Duplicate Therapy

Breyanzi (lisocabtagene maraleucel) is a CAR-T cell therapy — a one-time, individualized treatment that works through a fundamentally different mechanism than chemotherapy, targeted agents, or other cell therapies. A duplicate-therapy denial means Cigna has determined that another drug or treatment already approved or in use for you provides the same therapeutic benefit. For a CAR-T product, this classification is almost always clinically incorrect and is a strong candidate for appeal.

Duplicate-therapy denials for Breyanzi often arise from automated claims-processing logic that fails to account for the unique mechanism and patient population of CAR-T cell therapy. Your oncologist's documentation of why Breyanzi is not interchangeable with prior or concurrent treatments is the cornerstone of your appeal.

## Why This Denial Is Appealable

Breanzi is FDA-approved for specific relapsed or refractory hematologic malignancies. Its mechanism — reengineering your own T-cells to target cancer cells — is distinct from every other approved therapy class. An IRO reviewing a duplicate-therapy denial in the context of a CAR-T product will focus on whether the prior or concurrent therapy is, in fact, therapeutically equivalent. The clinical literature and FDA labeling strongly support the argument that it is not.

## Federal Appeal Framework

• Internal appeal (ERISA §503 / ACA §2719): File within 180 days of the denial. Cigna must decide standard appeals within 30 days (pre-service) or 60 days (post-service); expedited within 72 hours if clinically urgent.
• External review (ACA §2719): Available after exhausting internal appeals, generally within 4 months. An IRO with oncology expertise will evaluate the duplicate-therapy classification independently. Binding on Cigna.
• Expedited review: Request immediately if disease progression makes delay dangerous.

## Documentation to Gather

• Oncologist letter explaining that Breyanzi's CAR-T mechanism is distinct from each therapy cited as a "duplicate," and why prior therapies have failed or are not interchangeable
• Complete treatment history with dates, regimens, responses, and reasons for discontinuation of each prior line of therapy
• Pathology and staging records confirming the diagnosis and disease characteristics that make Breyanzi the appropriate choice
• FDA prescribing information for Breyanzi — the approved indications section directly rebuts any claim that a conventional therapy is equivalent
• Cigna's medical coverage policy for CAR-T/Breyanzi — identify the exact duplicate-therapy language and any exceptions

## Criteria-Mapping Structure

| Cigna's Basis for Duplicate Claim | Your Rebuttal Evidence | |---|---| | Therapy Cigna identified as "equivalent" | [Name the therapy; oncologist's statement of mechanistic difference] | | Why prior therapy does not substitute | [Treatment history showing failure, relapse, or ineligibility for that therapy] | | Breyanzi's unique mechanism | [Reference to FDA prescribing label; oncologist's explanation] | | Clinical guideline support | [Reference to applicable hematology guideline organization, e.g., NCCN, without quoting specific numbers] |

A well-supported appeal that documents the mechanistic distinction between Breyanzi and any cited duplicate has a strong basis for overturn, particularly at external review with an independent oncology reviewer.