CGRP mAb Subcutaneous denied for missing prior authorization by Cigna?

Cigna's specific coverage criteria for cgrp mab subcutaneous 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 Issued a Prior-Authorization-Required Denial for Your CGRP Monoclonal Antibody

Cigna requires prior authorization (PA) for CGRP monoclonal antibodies before the plan will cover the drug. A prior-auth-required denial typically means the prescription was dispensed or submitted to pharmacy without an approved PA on file, or the PA request was submitted but is still pending when the claim was processed. This is an administrative denial — it says nothing about whether you are clinically eligible — but it must be resolved before coverage begins.

## Why This Denial Is Appealable

If the PA was submitted but not yet decided, follow up directly with Cigna's PA unit for a status update and expedite if clinically urgent. If no PA was ever submitted, work with your prescriber to submit one immediately. If the PA was denied on clinical grounds and this denial is the result, see the separate medical-necessity or step-therapy guidance. In some circumstances — particularly when a prescriber's office experience establishes a pattern of PA delays causing treatment interruption — a retrospective PA appeal with documentation of medical urgency can result in back-coverage of claims already denied.

## Your Federal Appeal Rights

• ERISA §503 (self-funded plans) requires the plan to have a defined PA process with timely decisions; unreasonable delays in PA processing are themselves grounds for appeal.
• ACA §2719 external review applies after a final adverse benefit determination, including a denial resulting from a failed PA process.
• Expedited PA is available under federal rules when the standard timeline would seriously jeopardize the patient's life, health, or ability to regain maximum function — your prescriber can request expedited review in writing.
• The external-review window is generally approximately four months after final internal denial.

## Documentation to Gather

• PA submission confirmation: the PA reference number, submission date, and any Cigna acknowledgment; if none exists, document the submission gap and correct it immediately.
• Prescriber's PA request: the complete PA form submitted, including diagnosis codes, clinical rationale, and supporting notes; confirm all required fields were completed.
• Proof of medical urgency (for expedited PA or retrospective coverage): chart note establishing urgency, risk of treatment interruption, or clinical deterioration.
• Cigna's PA criteria: download the current CGRP PA criteria from cigna.com; your prescriber's clinical information should address every criterion listed.

## Process and Timeline

1. Confirm PA submission status with Cigna (call the provider line or check the portal). 2. If submitted and pending, request expedited status if clinically appropriate. 3. If not submitted, have the prescriber submit with complete clinical documentation now. 4. If PA denied on clinical grounds, file a formal internal appeal within Cigna's stated window (typically 180 days of denial). 5. If internal appeal denied, file for ACA §2719 external review within approximately four months.

Obtain the exact PA criteria from Cigna's current published CGRP coverage policy and the FDA-approved prescribing label before the prescriber submits, so the request is complete on first submission.