Haegarda denied for missing prior authorization 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 Requires Prior Authorization for Haegarda — and How to Navigate It

Haegarda (C1 esterase inhibitor subcutaneous) for hereditary angioedema (HAE) prophylaxis almost universally requires prior authorization (PA) from Cigna before the pharmacy or specialty distributor will dispense it. This is a cost-management step, not a clinical judgment, but it must be completed correctly to avoid denial. A PA denial — as opposed to a PA requirement — means Cigna reviewed the submission and found the documentation insufficient to satisfy its coverage criteria.

Most PA denials for Haegarda are overturned on appeal when complete clinical documentation is submitted, because the drug is FDA-approved and clinically supported for HAE prophylaxis.

## Your Federal Appeal Rights

• Internal appeal: Any adverse benefit determination, including a denied PA, triggers ERISA §503 or state-law appeal rights. File within the period stated on the denial letter (commonly 180 days).
• External review: After exhausting internal remedies, ACA §2719 provides independent external review — typically within approximately four months of final internal denial. Expedited PA appeals are available when a standard timeline would seriously jeopardize your health; an expedited decision is generally required within 72 hours.

## Concrete Appeal Steps

1. Request Cigna's written denial with the specific criteria that were not met. 2. Obtain Cigna's current prior-authorization criteria document for Haegarda — this lists every requirement you must satisfy. 3. Work with your prescriber to close each documentation gap identified in the denial. 4. Resubmit as a PA appeal (or, if time permits, a corrected PA resubmission) with the full documentation package. 5. If denied again, escalate to external review.

## Documentation to Gather

• Confirmed HAE diagnosis: type, genetic or complement confirmation, specialist evaluation
• Prior prophylactic treatment history: every agent tried, start/end dates, dose used per label, and documented clinical response
• Attack history: frequency, severity, emergency department or hospital visits, any airway involvement
• Current prescriber medical-necessity letter addressing each PA criterion directly
• Specialty-pharmacy records or infusion logs if prior C1-INH therapy has been administered

## Criteria-Mapping Structure

For a PA appeal, the most effective format is a one-to-one match between Cigna's PA criteria (copied verbatim from the policy) and the supporting chart evidence. For each criterion: reproduce the criterion exactly, then cite the corresponding chart note, lab result, or prescriber statement that satisfies it. Address any gap your prescriber has filled with a new clinical note. This prevents the reviewer from citing unmet criteria without a specific rebuttal.