Insulin Pump Tandem denied for missing prior authorization by Cigna?

Cigna's specific coverage criteria for insulin pump tandem 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 a Tandem Insulin Pump

Cigna treats insulin pumps as a covered-but-controlled benefit, meaning coverage is available but requires advance approval before the device is dispensed or the claim will be denied. Prior authorization (PA) exists because Cigna uses it to confirm that clinical criteria — typically documented in its medical coverage policy for insulin pumps — are met before it commits to coverage. A denial for "prior authorization required" almost always means either (a) no PA was submitted before dispensing, or (b) a PA was submitted and denied for a separate clinical reason. These are very different situations with different appeal strategies.

## Why This Denial Is Appealable

If the PA was never submitted, the appeal path is usually to work with your prescriber's office to submit one now and, if the plan allows, request a retroactive authorization. If a PA was submitted and denied, the underlying clinical reasons must be addressed in the appeal. Either way, Cigna is required under ACA §2719 and ERISA §503 to provide a full-and-fair review.

## Federal Appeal Framework

• Internal appeal: File within the deadline shown on your EOB or denial notice. Cigna must provide a written decision within the applicable timeframe (typically 30–60 days for standard reviews).
• External review: If the internal appeal is denied, you have approximately four months from the final adverse determination to request an IRO review under ACA §2719 external review rules.
• Expedited option: If your diabetes management would be seriously harmed by further delay — for example, if you are experiencing dangerous glycemic instability — request expedited review. Decisions on expedited appeals are generally required within 72 hours.

## Documentation to Gather

1. Diagnosis confirmation: Chart notes documenting your diabetes diagnosis type, duration, and current status. 2. Current therapy history: Records showing your insulin regimen history, frequency of hypoglycemic events, HbA1c trend over time, and any documented failure or limitations of your current delivery method — with dates and clinical outcomes. 3. Clinical severity evidence: Continuous glucose monitoring (CGM) data, hypoglycemia logs, or provider notes documenting the clinical burden that makes the pump medically necessary. 4. Prescriber medical-necessity letter: A detailed letter from your endocrinologist or treating physician explaining why the Tandem pump specifically is required, referencing applicable guidelines from the relevant professional organization (e.g., the applicable ADA or AACE guideline) without asserting specific numeric thresholds. 5. Cigna's coverage policy: Obtain Cigna's current published Medical Coverage Policy for insulin pumps directly from Cigna.com or via your EOB. Copy each listed criterion and document exactly how your chart satisfies it.

## Criteria-Mapping Structure

List each PA criterion from Cigna's policy. For each requirement, write one or two sentences referencing the specific chart evidence that satisfies it — for example, the visit date, provider name, lab result, or documented clinical event. This one-to-one mapping is the most persuasive structure for both internal and external reviewers.