Haegarda denied as not medically necessary by Cigna?

Cigna's specific coverage criteria for haegarda 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 Haegarda for Medical Necessity — and Why You Can Appeal

Haegarda is a subcutaneous C1 esterase inhibitor approved for long-term prophylaxis to prevent hereditary angioedema (HAE) attacks. Cigna's medical-necessity denial typically means the plan's reviewer concluded that the clinical criteria in Cigna's coverage policy were not sufficiently documented in the submitted record — not necessarily that the drug is wrong for you. Common gaps include insufficient documentation of attack frequency or severity, inadequate evidence of prior prophylactic trials, or a prescriber letter that does not address each criterion in Cigna's policy.

Medical-necessity denials are among the most common and most frequently overturned on appeal when complete documentation is provided.

## Your Federal Appeal Rights

• Internal appeal: ERISA §503 requires a full-and-fair internal review. File within the timeframe on your denial letter (often 180 days).
• External review: ACA §2719 provides access to an Independent Review Organization. File within approximately four months of final internal denial. Expedited review is available when delay would seriously jeopardize your health.

## Concrete Appeal Steps

1. Request Cigna's complete medical policy for Haegarda prophylaxis — obtain the exact version cited in your denial. 2. Review each listed criterion carefully with your prescriber. 3. Have your prescriber draft a detailed medical-necessity letter that addresses every criterion in the policy, supported by specific chart documentation. 4. Compile all supporting clinical records (see below). 5. Submit the internal appeal; track the response deadline and escalate to external review if needed.

## Documentation to Gather

• Confirmed HAE diagnosis (C1 inhibitor levels, C4, genetic confirmation if available, specialist evaluation)
• Treatment history: a chronological list of every HAE prophylactic and acute agent tried, with start/stop dates, doses used (per the prescribing label), and documented clinical outcomes
• Attack log: frequency, severity, emergency visits, hospitalizations, intubations, or airway events
• Quality-of-life impact: missed work, school, or functional limitations documented in chart notes
• Prescriber medical-necessity letter addressing Cigna's policy criteria point by point
• Any relevant specialty-society guidance (e.g., USHA, WAO/HAEI) cited generically

## Criteria-Mapping Structure

The single most effective appeal structure is a table or numbered list that reproduces each of Cigna's stated criteria verbatim, then immediately below each criterion cites the specific chart fact, date, and document that satisfies it. If any criterion is not yet fully documented, your prescriber should add a clinical note to the chart before the appeal is filed.