Fertility Germline Testing denied for missing prior authorization 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 Lack of Prior Authorization — and How to Fix It

Cigna requires prior authorization (PA) for many germline genetic tests ordered in a fertility or reproductive medicine context. When a test is performed without first obtaining that authorization — or when a PA was submitted but deemed incomplete — the claim is denied as "prior authorization required" or "authorization not obtained." This is a procedural denial rather than a clinical one, but it can still result in the patient bearing the full cost if not properly appealed.

## Why This Denial Is Appealable

Procedural PA denials are among the most commonly overturned on appeal, particularly when (a) the provider believed authorization was on file or was not notified of the requirement, (b) the test was ordered emergently or urgently, or (c) the PA was submitted but processed incorrectly. Even where the procedural lapse is clear, many plans have provisions allowing retroactive authorization when medical necessity can be demonstrated. A concurrent appeal on medical-necessity grounds alongside the procedural appeal substantially improves the outcome.

## Your Federal Appeal Rights

• Internal appeal: Under ERISA §503 (employer plans) or applicable state law, you are entitled to a full-and-fair internal review. File within the deadline on your EOB — typically 180 days.
• Retroactive authorization request: File this simultaneously with your internal appeal, through Cigna's utilization management line. The two processes can run in parallel.
• External review: Under ACA §2719, binding external review is available once internal remedies are exhausted. Total window is approximately four months. Expedited review (72 hours) applies when your health situation is urgent.

## Concrete Appeal Steps and Timeline

1. Confirm authorization requirements — pull the current Cigna PA list for the test's CPT code(s) to verify PA was actually required at the time of service. 2. Contact the ordering provider — they should initiate a retroactive PA request and confirm whether they believed authorization was in place. 3. File internal appeal and retroactive PA simultaneously, within the EOB deadline. 4. If retroactive PA is denied, escalate both the authorization denial and the underlying claim denial together to external review.

## Documentation to Gather

• PA submission records: Fax confirmations, portal records, or any evidence that the provider submitted (or attempted to submit) a PA request.
• Ordering provider attestation: A signed statement that the test was medically necessary and, if applicable, that the provider was unaware of or misinformed about the PA requirement.
• Clinical necessity documentation: Diagnosis notes, specialist letters, and relevant history — medical necessity is evaluated even in retroactive PA decisions.
• Urgency documentation: If the test was ordered on an urgent basis that precluded pre-authorization, document that clinical urgency explicitly.
• Cigna PA criteria: The authorization criteria in effect at the time of the order, to confirm the test met every stated threshold.

## Criteria-Mapping Structure

In your appeal letter, first address the procedural question (why the absence of prior authorization should be excused), then address each medical-necessity criterion from Cigna's PA guidelines using the exact chart facts that satisfy them. Resolving both layers in one submission saves time and prevents Cigna from upholding on procedural grounds while never reaching the clinical merits.