Evrysdi denied for missing prior authorization 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 Requires Prior Authorization for Evrysdi

Cigna requires prior authorization (PA) for Evrysdi (risdiplam) because it is a high-cost specialty medication for spinal muscular atrophy (SMA). The PA process is Cigna's mechanism for confirming that the patient meets its clinical coverage criteria before the drug is dispensed. A denial at the PA stage means the submitted information was incomplete, did not match Cigna's criteria, or the request was submitted without all required documentation.

This is not a final no. A PA denial triggers a full appeal right, and the majority of SMA PA denials are overturned when the appeal includes complete clinical documentation.

## Why It Is Appealable

Under ACA §2719, plans must provide a full internal appeal and access to independent external review for any adverse benefit determination, including PA denials. Under ERISA §503, self-funded plans must give a full-and-fair review and provide the claims file on request. You have 180 days from the denial notice to file an internal appeal. External review must be requested within four months of the final adverse internal decision. Expedited review — typically resolved in 72 hours — is available when a clinician certifies that standard timelines would seriously jeopardize health. For ongoing SMA treatment, this standard is frequently met.

## Appeal Process and Timeline

1. Peer-to-peer call first — have the prescribing neurologist call Cigna's medical director immediately after the PA denial. This single step resolves a large share of SMA PA denials before a formal appeal is needed. 2. Request the denial rationale — Cigna must tell you which specific clinical criterion was not met. 3. Formal internal appeal — submit within 180 days with the complete documentation package below. 4. Cigna's decision — 30 days for non-urgent pre-service; 72 hours for expedited. 5. External review — file within four months of a final adverse internal decision.

## Documentation to Gather

• Genetic testing results — SMN1 deletion/mutation confirmation and SMN2 copy number analysis, with the lab name and date.
• SMA type and onset documentation — neurologist's diagnosis note, SMA type classification, and age of symptom onset.
• Current functional status — standardized motor function assessment performed by the treating team within a clinically appropriate recent timeframe, with date.
• Pulmonary and swallowing assessment — as clinically applicable to the patient's SMA type.
• Prescriber medical-necessity letter — specifically addressing each of Cigna's published PA criteria for risdiplam, confirming that each criterion is met and citing the supporting chart document.
• Prior therapy history — if the patient has received or attempted other SMA-directed therapy, document outcomes and rationale for the current request.

## Criteria-Mapping Structure

Obtain Cigna's current PA criteria for Evrysdi from the Cigna medical policy page or by requesting it during the denial notice process. Obtain the FDA-approved prescribing label from the FDA website. Create a table with three columns: (1) Cigna's criterion, (2) FDA label requirement, (3) patient's chart evidence. Address every criterion in writing. PA denials are frequently the result of a simple documentation gap — one missing test result or a prescriber letter that doesn't explicitly map to the plan's stated criteria. A complete, mapped submission at the appeal stage produces the highest reversal rate.