Inspire HGNS denied as non-formulary by Cigna?

Cigna's specific coverage criteria for inspire hgns 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 the Inspire HGNS System as Non-Formulary — and Why You Can Appeal

Although "formulary" language is most commonly associated with prescription drugs, Cigna and other large insurers apply analogous tiering concepts to implantable devices and durable medical equipment. A non-formulary denial for the Inspire Hypoglossal Nerve Stimulation system typically means the device was not on Cigna's preferred device list, was directed to a non-contracted surgical facility, or was submitted under a code not mapped to an active coverage policy. It does not mean the device is excluded — it means it was routed to the wrong coverage pathway.

Non-formulary denials are highly procedural and frequently resolved at the first appeal level when the underlying clinical need is documented and the correct coverage pathway is identified.

## Federal Appeal Rights

ACA §2719 requires non-grandfathered plans to offer at least two internal appeals and access to independent external review. ERISA §503 mandates full-and-fair review for employer-sponsored plan participants. External review must typically be requested within 180 days of the denial notice — check your Explanation of Benefits for the exact window. Expedited review is available in urgent clinical circumstances, with a decision generally within 72 hours.

## Concrete Appeal Process

1. Call Cigna's provider services line to identify whether the denial stems from a formulary exclusion, a network/facility issue, or a coding mismatch — the resolution path differs for each. 2. Request Cigna's medical policy and any device coverage bulletin for hypoglossal nerve stimulation to confirm coverage exists under a different pathway. 3. File a Level 1 internal appeal that simultaneously (a) establishes medical necessity and (b) addresses the procedural basis for the non-formulary flag — such as confirming the facility was in-network or that the correct HCPCS codes were used. 4. If denied, proceed to Level 2 internal appeal and then independent external review.

## Documentation to Gather

• Diagnosis and severity: Polysomnography report and physician notes documenting the clinical case for HGNS.
• PAP-therapy failure: Dated records of PAP initiation, adherence data, and clinical discontinuation rationale.
• Facility and network documentation: Confirmation that the implanting facility and surgeon are in-network under the patient's specific Cigna plan, or a prior-authorization record that referenced an approved facility.
• Device and coding records: Operative report, device serial/model information, and the HCPCS/CPT codes billed — cross-referenced against Cigna's published coverage policy to confirm alignment.
• Prescriber medical-necessity letter: Addresses both the clinical indication and, if relevant, explains why the specific facility was chosen.

## Criteria-Mapping Structure

Divide your appeal into two sections: (1) Clinical Necessity — mapping each of Cigna's coverage criteria to specific chart findings; and (2) Coverage Pathway Clarification — identifying the procedural reason for the non-formulary flag and providing the document that resolves it. Addressing both dimensions in a single submission is more efficient and avoids a second denial on procedural grounds after winning the clinical argument.