Fscig Hyqvia denied for missing prior authorization by Cigna?

Cigna's specific coverage criteria for fscig hyqvia 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 HyQvia for "Prior Authorization Required" — and How to Appeal

HyQvia (immune globulin infusion 10% with recombinant human hyaluronidase) is a specialty biologic that Cigna places on a tier requiring prior authorization before dispensing. A denial under this reason code means either that no authorization was obtained before the prescription was filled or administered, or that an authorization was submitted but deemed incomplete or not approved before service. This is one of the most procedurally correctable denial types.

## Why This Denial Is Frequently Resolved on Appeal

If the medication was genuinely medically necessary and your diagnosis qualifies under Cigna's coverage criteria, a retroactive or prospective prior-authorization appeal can succeed — particularly when the original submission was incomplete, when there was an urgent clinical need, or when the prescriber can now supply documentation that was missing from the initial request. Cigna's own clinical coverage policy sets out the criteria; meeting each one point-by-point is the key.

## Federal Appeal Framework

• Internal appeal — File within the deadline on your Explanation of Benefits (commonly 180 days). Request the specific criteria Cigna used; ERISA §503 entitles self-funded plan members to this information.
• Concurrent or expedited review — If you are currently receiving HyQvia infusions, ask immediately whether Cigna will continue coverage during the appeal to avoid a treatment gap.
• ACA §2719 external review — After exhausting internal appeals, you may request an Independent Review Organization determination. The window is typically around four months from the internal adverse decision; confirm the exact date on your denial notice.
• Expedited external review — Request this if interrupting therapy would seriously jeopardize your health; a decision is typically required within 72 hours.

## Documentation to Gather

• Diagnosis confirmation — Specialist notes establishing the primary immunodeficiency diagnosis, including relevant immunologic testing results referenced (but not numerically quoted) by your clinician.
• Prior treatment history — Dates and outcomes of prior immunoglobulin therapy, including any intravenous formulations tried and the reasons subcutaneous administration via HyQvia is now indicated (e.g., tolerability, venous access, quality-of-life factors documented in the chart).
• Prescriber medical-necessity letter — Signed attestation that HyQvia meets the FDA-approved indication for your specific diagnosis and that the prescriber has reviewed Cigna's coverage criteria.
• FDA prescribing label — Attach the current label; use it to demonstrate the on-label basis for the prescription.
• Cigna coverage policy — Download or request Cigna's current clinical coverage policy for immune globulin therapy. Every criterion should be addressed individually in your appeal letter.

## Criteria-Mapping Structure

| Cigna Policy Criterion | Documented Evidence | |---|---| | FDA-approved indication confirmed | Specialist note + diagnosis code | | Qualifying diagnosis per policy | Chart entry with date and clinical detail | | Any required prior therapy step | Treatment history with dates and outcomes | | Each additional policy requirement | Specific chart reference or test result |

A point-by-point table submitted alongside the prescriber letter dramatically increases the chance of overturn at internal review, often avoiding the need for an IRO.