Evrysdi denied as not medically necessary 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 for Medical Necessity

A medical-necessity denial for Evrysdi (risdiplam) in spinal muscular atrophy (SMA) typically means Cigna's clinical reviewer determined that the submitted documentation did not sufficiently establish that the therapy is medically required for this patient at this time. Common gaps include an incomplete functional assessment, missing genetic confirmation, insufficient documentation of disease progression, or a failure to show that the patient's presentation falls within the coverage parameters of Cigna's SMA clinical policy.

This is one of the most reversible denial categories when the appeal is built on thorough, well-organized clinical evidence.

## Why It Is Appealable

Under ACA §2719, all non-grandfathered plans must provide internal appeals and access to independent external review for adverse benefit determinations. Under ERISA §503, self-funded plans must give a full-and-fair review and provide the complete claims file on request. You have 180 days from the denial notice to file an internal appeal. If the internal appeal fails, external review must be requested within four months. Expedited review is available — typically resolved in 72 hours — when a clinician certifies that the standard timeline would materially harm the patient.

## Appeal Process and Timeline

1. Request the full denial package — Cigna's specific clinical criteria, the reviewer's credentials, and all documents relied on. 2. Internal appeal — Cigna has 30 days to decide a non-urgent pre-service appeal and 60 days for post-service. Submit all new clinical evidence with this filing. 3. External review — after a final adverse internal decision, file with the designated IRO within four months. 4. Peer-to-peer call — your prescriber should request a peer-to-peer conversation with Cigna's medical director before or alongside the formal appeal; this step alone resolves a significant share of SMA denials.

## Documentation to Gather

• Genetic confirmation — SMN1 deletion/mutation report and SMN2 copy number result, with the testing lab's name and date.
• SMA type and onset documentation — neurology notes establishing type (I, II, III, or IV), age of symptom onset, and current functional status.
• Objective functional assessments — standardized motor function evaluations performed by the treating team, with dates, showing current severity and trajectory.
• Pulmonary and nutritional status — respiratory function testing, swallowing evaluation, nutritional assessments as clinically applicable.
• Prescriber medical-necessity letter — a detailed letter from the neurologist explaining why Evrysdi is appropriate for this patient's specific SMA type, functional level, and clinical trajectory, and why it aligns with current SMA management guidelines from the relevant neuromuscular society.
• Prior treatment history — if the patient has received other SMA therapies, document the outcomes and the clinical rationale for transitioning.

## Criteria-Mapping Structure

Obtain Cigna's current SMA coverage policy and the FDA-approved prescribing label for risdiplam. Create a two-column table: left column lists each coverage criterion; right column cites the exact chart document, date, and finding that satisfies it. This mapping discipline ensures no criterion is left unanswered and makes it straightforward for the reviewing clinician or IRO reviewer to confirm coverage. Appeals that address every criterion explicitly are far more likely to succeed than narrative letters alone.