Inspire HGNS denied for missing prior authorization 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 for Missing Prior Authorization — and Why You Can Appeal

A prior-authorization-required denial means Cigna was not asked for approval before the procedure occurred — or that a prior-authorization request was submitted but not resolved before the implant date. For the Inspire Hypoglossal Nerve Stimulation system, a complex implantable device, prior authorization is expected under virtually all Cigna commercial plans. When it is missing, Cigna denies the claim on procedural grounds regardless of clinical merit.

These denials are appealable, though the strategy differs depending on whether the surgery was elective or urgent. For elective procedures, the appeal must demonstrate either that prior auth was actually obtained (documentation issue) or argue retrospective authorization. For urgent or emergency situations, federal law limits the insurer's ability to deny on prior-auth grounds alone.

## Federal Appeal Rights

ACA §2719 and ERISA §503 both apply to this denial type. You have at minimum two internal appeal levels and access to independent external review. The external-review window is typically 180 days from the denial notice — verify on your Explanation of Benefits. Expedited review is available for urgent situations and typically resolves within 72 hours.

## Concrete Appeal Process

1. Determine whether prior auth was requested: Check with the implanting facility's billing team. If an authorization number exists, the denial is a records error — attach the authorization confirmation to a Level 1 appeal and request expedited resolution. 2. If no prior auth was requested: File a Level 1 internal appeal requesting retroactive authorization. The appeal must establish that (a) the clinical criteria for coverage are fully met, and (b) either the omission of prior auth was a provider administrative error (not a patient error) or that the urgency of the procedure made pre-authorization impractical. 3. Review your plan documents for a retrospective review provision — most Cigna plans permit it within a defined window after the service date. 4. Escalate to Level 2 internal appeal and then independent external review if initial appeals fail.

## Documentation to Gather

• Authorization records: Any prior-authorization reference numbers, submission confirmation emails, or fax logs from the provider's office.
• Plan documents: The Summary Plan Description or Evidence of Coverage confirming the prior-auth requirement and the retroactive review process.
• Diagnosis and severity: Polysomnography, physician notes, and PAP-failure records demonstrating full clinical eligibility for HGNS.
• Urgency documentation (if applicable): Physician statement explaining why the procedure could not be delayed and why pre-authorization was not feasible in the available time.
• Prescriber medical-necessity letter: Establishes that all of Cigna's clinical coverage criteria were met at the time of the procedure, supporting retroactive authorization.

## Criteria-Mapping Structure

Structure the appeal in two parts. Part 1 — Procedural Argument: address the prior-auth gap directly, citing the retrospective review provision and any mitigating factors. Part 2 — Clinical Eligibility: map each of Cigna's coverage criteria for HGNS to the corresponding chart finding, demonstrating that authorization would have been granted had it been requested. This dual structure anticipates Cigna's response and closes the most common grounds for upholding the denial.