Isturisa denied as not medically necessary by Cigna?

Cigna's specific coverage criteria for isturisa 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 Isturisa for Medical Necessity

A medical-necessity denial means Cigna's reviewer determined that the information submitted — or available in the record at the time of the decision — did not satisfy every criterion in the plan's coverage policy for Isturisa (osilodrostat). For a specialty drug used in Cushing's disease, these criteria typically address the confirmed diagnosis, the severity of active hypercortisolism, and the clinical history preceding the prescription.

Medical-necessity denials are frequently overturned on appeal when the clinical record is organized to directly address each policy criterion. A denial at the initial authorization stage does not mean the drug is excluded — it means the documentation gap needs to be closed.

## Federal Appeal Framework

• ACA §2719 / ERISA §503: You are entitled to a full-and-fair internal appeal. Cigna must provide you with the specific reason for denial and the clinical criteria applied upon request.
• Access to criteria: You have the right to receive a copy of the medical policy and any clinical guidelines used in the determination. Request these in writing immediately.
• External review: If the internal appeal is denied, escalate to an independent review organization (IRO). You generally have approximately four months from the denial date to file; confirm your exact deadline from the denial letter.
• Expedited review: If your condition makes delay medically dangerous, request expedited review at both the internal and external levels.

## Concrete Appeal Process and Timeline

1. Request the full denial reason and the Cigna medical policy used — you are entitled to these in writing. 2. Have the treating endocrinologist review the specific criteria and identify any documentation gaps in the current record. 3. Submit a written internal appeal with the complete clinical package (see below) within Cigna's stated deadline, typically 180 days from the denial. 4. Cigna must respond within 30 days (prospective/concurrent) or 60 days (retrospective). 5. If the internal appeal is denied, file for IRO external review before your four-month window closes.

## Documentation to Gather

• Diagnosis confirmation: Formal endocrinology evaluation confirming Cushing's disease — biochemical testing results (the type and interpretation, not raw numbers), pituitary imaging, and the clinical visit notes establishing the diagnosis.
• Prior-treatment history with dates and outcomes: A chronological list of every prior medical, surgical, or radiation treatment attempted — what was tried, when, for how long, and what the clinical outcome was. Chart notes are stronger than summary letters.
• Clinical severity per the chart: Current symptom burden and functional status as documented in office notes — not just a letter written for the appeal.
• Prescriber medical-necessity letter: A structured letter from the endocrinologist that maps each of Cigna's policy criteria to a specific fact in the medical record, explains why Isturisa is the appropriate next step, and references the FDA-approved prescribing information and the applicable endocrinology society guidelines.

## Criteria-Mapping Structure

Obtain Cigna's current coverage policy for Isturisa. For every listed criterion, create a two-column table:

| Cigna Policy Criterion | Chart Evidence (source, date) | |---|---| | Confirmed diagnosis of Cushing's disease | [Diagnostic workup, date, clinician] | | Inadequate response to or intolerance of prior therapy | [Prior agent, dates, documented outcome] | | Prescriber specialty requirement met | [Endocrinologist name, credentials] | | Other plan-specific criteria | [Corresponding chart documentation] |

Attach every referenced record. Reviewers — and IRO physicians — approve appeals fastest when the submission answers each criterion in order rather than presenting a general clinical narrative.