Fertility Germline Testing denied as not medically necessary by Cigna?

Cigna's specific coverage criteria for fertility germline testing 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 Denies Germline Testing for Fertility Purposes — and Why You Can Appeal

Germline (hereditary) genetic testing ordered in a fertility context — such as carrier screening, preimplantation genetic testing for monogenic conditions (PGT-M), or hereditary cancer testing that informs reproductive decisions — is frequently denied by Cigna on medical-necessity grounds. Cigna's medical policy requires clinical documentation establishing that the testing is indicated by a specific diagnosis or risk profile, not ordered as a routine screen. When that documentation is thin or absent from the submitted record, a medical-necessity denial almost always follows.

## Why This Denial Is Appealable

Medical-necessity determinations are among the most successfully overturned categories on appeal. The denial is reviewable because it rests on a factual judgment about your clinical situation — a judgment that can be rebutted with the right documentation. Professional societies in reproductive medicine and medical genetics have published guidelines supporting germline testing in well-defined clinical scenarios; referencing the applicable guideline organization (without fabricating specific numbers) strengthens your case.

## Your Federal Appeal Rights

• Internal appeal: You have the right to a full internal review under ERISA §503 (employer plans) or applicable state law (individual/fully-insured plans). Submit within the timeframe shown on your denial letter — typically 180 days.
• External review: Under ACA §2719, once internal remedies are exhausted you may request an independent external review by an accredited Independent Review Organization (IRO). The IRO's decision is binding on the insurer. The standard window is approximately four months from denial, but expedited external review (decision within 72 hours) is available when your health is at serious risk.

## Concrete Appeal Steps and Timeline

1. Request the denial file — ask Cigna for the complete claim file and the specific medical-policy criteria used to deny. 2. File the internal appeal — submit within the deadline on your Explanation of Benefits (EOB). Most plans allow 180 days. 3. Request external review — if the internal appeal is upheld, submit an external-review request immediately. 4. Document expedited grounds — if delay would cause serious harm, request expedited review in writing.

## Documentation to Gather

• Diagnosis confirmation: Provider notes establishing the clinical indication (e.g., personal or family history of a hereditary condition, specific reproductive diagnosis).
• Prior workup history: Records showing any prior testing performed, with dates and results, demonstrating this test is the appropriate next step.
• Clinical severity and risk: Specialist notes quantifying the patient's risk profile in clinical terms — without inventing numbers, document what the chart actually says.
• Prescriber medical-necessity letter: A signed letter from the ordering physician or genetic counselor explaining why germline testing is medically necessary for this specific patient, citing the applicable professional society guideline by organization name.
• Applicable guidelines: Reference the relevant guideline body (e.g., ACOG, NSGC, ASRM, or applicable NCCN guideline) without fabricating statistics.

## Criteria-Mapping Structure

Pull Cigna's published coverage policy for germline/hereditary genetic testing. List every stated requirement. For each requirement, write the exact chart fact that satisfies it. Present this as a numbered table in your appeal letter — criterion on the left, your documented evidence on the right. This structure forces the reviewer to address each element individually and makes a blanket uphold much harder to sustain.