Evrysdi denied as duplicate or overlapping therapy by Cigna?

Cigna's specific coverage criteria for evrysdi 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 Evrysdi as Duplicate Therapy

Cigna's duplicate-therapy denial means the plan has determined that another drug already on your benefit profile addresses the same clinical indication — in this case, spinal muscular atrophy (SMA). Because Evrysdi (risdiplam), Spinraza (nusinersen), and Zolgensma (onasemnogene abeparvovec) all target SMA, Cigna's clinical policy typically permits only one SMA-directed therapy at a time and will flag a second as duplicative.

This denial is routinely overturned when the record demonstrates that the currently covered therapy is clinically inadequate, contraindicated, or inaccessible for the specific patient.

## Why It Is Appealable

The duplicate-therapy rationale is a medical-necessity determination in disguise. Under ACA §2719 and its implementing regulations, non-grandfathered individual and small-group plans must provide a full internal appeal and access to independent external review. ERISA §503 requires self-funded employer plans to give a full-and-fair review with the right to review the complete claims file. You generally have 180 days from the denial notice to file an internal appeal, and external review must be requested within four months of an adverse internal decision. An expedited review (often resolved in 72 hours) is available when your clinician certifies that standard timelines would seriously jeopardize health.

## Appeal Process and Timeline

1. Request the denial file — Cigna must provide the specific clinical criteria used and the reviewer's credentials within a set number of business days of your request. 2. Level 1 internal appeal — Submit within 180 days. Cigna has 30 days for non-urgent pre-service and 60 days for post-service appeals. 3. Level 2 internal appeal (if offered) — Cigna may offer a voluntary second review; use it to add new clinical evidence. 4. External review — File with Cigna's designated Independent Review Organization (IRO) within four months of the final adverse internal decision.

## Documentation to Gather

• SMA diagnosis confirmation — genetic testing results, neurology evaluation, type classification (SMA type I, II, III, or IV).
• Prior therapy history — dates initiated, all doses and adjustments made, objective functional assessments over time (motor function scales, pulmonary function, swallowing studies).
• Evidence of inadequacy — documented progression or plateau on the current therapy, with dated chart entries.
• Prescriber medical-necessity letter — specifically addressing why the prior therapy is insufficient and why Evrysdi's oral route of administration or distinct mechanism provides a clinically meaningful difference for this patient.
• Relevant guideline support — reference the applicable SMA management guidelines from the relevant neuromuscular society; do not cite specific numbers, but note that your prescriber's judgment aligns with those guidelines.

## Criteria-Mapping Structure

Copy each requirement listed in Cigna's published SMA clinical policy and Evrysdi's FDA-approved prescribing label. For every line item, write the exact matching fact from the patient's chart (date, test result, clinical note). Insurers deny duplicate-therapy claims but routinely reverse on appeal when the record shows the prior agent has objectively failed or cannot be used safely. A point-by-point mapping leaves no ambiguity.