IPF Ofev denied for missing prior authorization by Cigna?

Cigna's specific coverage criteria for ipf ofev 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 Ofev (nintedanib) in IPF

Cigna requires prior authorization for Ofev because it is a high-cost specialty medication for a serious chronic disease. Prior authorization is not a denial of coverage — it is a pre-approval step the prescriber must complete before the pharmacy claim will process. When a prior-auth-required denial appears on an Explanation of Benefits, it typically means either that no prior authorization was submitted before the prescription was filled, or that a submitted authorization request is still pending or was itself denied. Understanding which situation applies determines the correct next step.

## Why This Is Appealable (When the PA Was Denied)

If the prior authorization request itself was submitted and denied, that adverse determination is a fully appealable coverage decision under the same federal framework as any other denial. Cigna must provide a written denial reason, and you have the right to internal and external appeal. If the PA was simply never submitted, the prescriber should submit one immediately — a retro-authorization request may be available if the drug was already dispensed.

## Federal Appeal Framework

• Prior authorization submission: If no PA was submitted, the prescriber initiates one through Cigna's provider portal or by phone. The prescriber's office manages this process, but you can ask for updates.
• Internal appeal of PA denial: File within the timeframe on your Explanation of Benefits. Cigna must decide within 30 days (prospective, non-urgent) or 72 hours (expedited).
• External review (ACA §2719): After an adverse internal decision on the PA denial, you may request independent external review. The window is generally up to four months from the denial notice.
• ERISA §503: Employer-plan members have federal full-and-fair review rights including access to Cigna's clinical criteria.
• Expedited PA and appeal: If your prescriber certifies that waiting would seriously jeopardize your health, expedited review is available and should be invoked at every level.

## Documentation to Gather

1. Diagnosis confirmation — Specialist (pulmonologist) records documenting IPF, including HRCT and pulmonary function test results. 2. Disease severity — Chart documentation of disease progression, functional status, and clinical urgency. 3. Prescriber medical-necessity letter — Specialty prescriber explains the IPF diagnosis, disease course, rationale for Ofev, and alignment with the applicable professional guideline organization (e.g., ATS/ERS/JRS/ALAT). 4. Prior-treatment history — Any prior antifibrotic agents trialed, with dates and outcomes; or clinical rationale for initiating with this agent if no prior therapy. 5. PA criteria checklist — Obtain Cigna's published PA criteria for Ofev and have the prescriber's letter address each criterion explicitly.

## Criteria-Mapping Structure

Cigna's prior-authorization criteria for antifibrotics in IPF are published in its coverage policies and are available through the provider portal. Obtain the current version. For each listed criterion, cite:

• Confirmed IPF diagnosis by a qualified specialist — chart and specialist records
• Disease severity consistent with treatment initiation per the prescribing label and the applicable guideline organization (reference the organization; exact thresholds are in the label and in Cigna's published policy)
• Appropriate prescriber specialty and treatment oversight plan
• Prior therapy history or justification for initial agent selection

A PA packet that pre-answers every published criterion reduces back-and-forth and accelerates approval.