Checkpoint Inhibitor denied for missing prior authorization by Cigna?

Cigna's specific coverage criteria for checkpoint inhibitor 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 Your Checkpoint Inhibitor — Prior Authorization Required

Checkpoint inhibitors are high-cost specialty oncology agents, and Cigna requires prior authorization (PA) for all of them. A denial for "prior-auth-required" typically means the drug was administered or prescribed before the PA was obtained, or the PA request was submitted but deemed incomplete. This is one of the most routinely reversed denial types in oncology — it does not mean Cigna determined the treatment is medically unnecessary.

## Federal Appeal Framework

• Internal appeal: Submit within 180 days of the denial notice. For urgent cancer treatment, invoke the expedited track (72-hour decision required).
• Concurrent retroactive PA: If treatment has already started, simultaneously file a retroactive PA request and an appeal; argue that any delay in filing was clinically justified.
• ACA §2719 external review: Available after the internal process, within the ~4-month statutory window. An independent review organization evaluates whether the denial meets medical-necessity and coverage criteria.
• ERISA §503 (employer plans): Entitles you to the full administrative record and the specific coverage criteria applied.

## Documentation to Gather

1. Complete PA submission packet: Confirm the prescriber submitted all required clinical information — diagnosis, ICD-10 code, drug and administration route, biomarker results, staging, and line of therapy. 2. Prescriber medical-necessity letter: A detailed letter explaining the clinical rationale, addressing each of Cigna's PA criteria explicitly. 3. Biomarker and pathology records: PD-L1 expression, MSI/TMB status, genomic report — whichever markers are relevant to the specific checkpoint inhibitor and indication. 4. Prior treatment history: Chart documentation of all prior systemic therapies with dates and response or toxicity outcomes. 5. Cigna's PA criteria: Request the specific prior-authorization guidelines Cigna applied. You are entitled to this under ERISA or ACA rules.

## Criteria-Mapping Structure

Obtain the FDA-approved prescribing label for the specific checkpoint inhibitor and Cigna's current prior-authorization policy. List each PA criterion side by side with the chart evidence that satisfies it. For example: if the policy requires documented biomarker testing, attach the lab report with result and date. This structured mapping prevents a second denial on missing documentation grounds.

If treatment is ongoing and interruption poses clinical harm, include the oncologist's statement about the risks of treatment delay — this strengthens the case for expedited review and can be decisive in both internal and external review.