Forteo denied for missing prior authorization by Cigna?

Cigna's specific coverage criteria for forteo 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 Forteo for Lack of Prior Authorization

A prior-authorization (PA) denial for teriparatide (Forteo) means the drug was dispensed or the claim was submitted without a completed PA on file, or that a PA was submitted and did not meet Cigna's clinical criteria. This is among the most common — and most recoverable — denial types. The process differs slightly depending on whether the PA was never submitted versus submitted and denied on clinical grounds.

## Federal Appeal Framework

• If PA was never submitted: Your prescriber's office can submit a new PA request prospectively. This is not an appeal but a new authorization request — act on it immediately because teriparatide is a time-sensitive therapy.
• If PA was submitted and denied clinically: File an internal appeal within the deadline on the denial notice. Cigna must respond within 30 days (non-urgent). An expedited PA review (72 hours) is available when your health situation requires it.
• External review (ACA §2719 / ERISA §503): If the internal appeal is denied, request independent external review within approximately 4 months. An IRO independent of Cigna evaluates whether your clinical profile meets the applicable standard.

## Documentation to Gather

1. Diagnosis and severity: DXA scan, fracture history, physician notes documenting the clinical basis for teriparatide. 2. Prior-treatment history: Complete, dated record of every prior osteoporosis medication — what was tried, when, duration, dose, and outcome. This is typically the most scrutinized element of a teriparatide PA. 3. Prescriber medical-necessity letter: A detailed letter from the treating physician addressing each criterion in Cigna's published prior-authorization criteria for teriparatide. Generic letters are frequently insufficient — the letter must be criterion-specific. 4. Applicable clinical guideline reference: Your prescriber should note the relevant guideline organization (e.g., AACE/ACE, Endocrine Society) that supports the proposed use.

## Criteria-Mapping Structure

Obtain Cigna's current prior-authorization criteria for teriparatide — available through Cigna's provider portal or by calling provider services. Download the FDA-approved prescribing label. For each PA criterion Cigna lists, provide the specific chart fact, date, and provider name that satisfies it. Present this as a structured table at the front of the appeal or PA resubmission. Reviewers work from checklists; a matching checklist dramatically shortens review time and improves reversal rates.