Forteo denied for failing step therapy 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 Due to Step Therapy

Step-therapy (also called "fail first") denials for teriparatide (Forteo) occur because Cigna's policy requires documented failure of one or more preferred-tier osteoporosis medications before it will authorize an anabolic agent. This is one of the most common denial types for teriparatide and one of the most frequently overturned — because the required step drugs are typically antiresorptive agents with a fundamentally different mechanism, and many patients have already tried them or have clinical reasons they are not appropriate.

## Federal Appeal Framework

• Step-therapy override laws: Many states have enacted step-therapy override statutes that require insurers to grant exceptions when a required step drug has already been tried, is contraindicated, or would cause clinically significant harm. Confirm whether your state's law applies to your plan type.
• Internal appeal: File within the deadline on your denial notice. Cigna must decide within 30 days for non-urgent requests. An expedited decision (72 hours) is available when delay poses a serious health risk.
• External review (ACA §2719 / ERISA §503): After an internal denial, request independent external review within approximately 4 months. The IRO evaluates whether the step-therapy requirement as applied to your case is clinically appropriate.

## Documentation to Gather

1. Step-drug history: A complete, dated list of every required step medication you have taken — drug name, dates, duration, dose, and documented reason for stopping (inadequate response, intolerance, adverse effect, contraindication per your physician). This is the single most important document. 2. Clinical severity evidence: DXA results, fracture history, and physician notes documenting urgency or the risk posed by delaying anabolic therapy while retrying antiresorptive agents. 3. Mechanistic distinction: If the step drugs are antiresorptive and your prescriber believes an anabolic mechanism is required, a letter explaining the clinical difference and why the step drugs do not adequately address your situation is essential. 4. Prescriber medical-necessity letter: A letter addressing each step drug Cigna requires, confirming prior trial or documenting why each is clinically inappropriate, and requesting a step-therapy exception.

## Criteria-Mapping Structure

Obtain Cigna's step-therapy criteria for teriparatide from the prior-authorization guidelines. List each required step drug and the evidence Cigna requires of prior failure or contraindication. For each step drug, document the specific chart entry — date, drug, outcome — that satisfies or waives that step. Present this as a table so the reviewer can confirm each step without searching through narrative notes.