Isturisa denied for missing prior authorization 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 Required Prior Authorization for Isturisa

A prior-authorization-required denial means Cigna did not receive or approve the required pre-approval request before Isturisa (osilodrostat) was dispensed or prescribed. This is one of the most common denial types for specialty medications and is nearly always resolvable — either through the standard prior-authorization process or, if authorization was wrongly denied, through the internal and external appeal process.

For Isturisa, prior authorization is standard practice given the drug's specialty-tier status and the clinical complexity of Cushing's disease. The key is ensuring the submission is complete and directly addresses each coverage criterion.

## Federal Appeal Framework

• ACA §2719 / ERISA §503: If a prior-authorization request is submitted and denied, you have the right to a full internal appeal and, if that fails, to external review by an independent review organization (IRO).
• Retrospective review: If the drug was already dispensed without authorization, you may still appeal on the grounds of medical necessity and urgency — document why prior authorization could not be obtained in advance if relevant.
• External review deadline: You generally have approximately four months from the denial notice to file for IRO review — verify your exact deadline from the denial letter.
• Expedited option: If delay would seriously harm your health, request expedited review at both the internal and external levels.

## Concrete Appeal Process and Timeline

1. Confirm whether the denial is a "PA not submitted" administrative denial or a "PA submitted and denied" medical-necessity denial — the path forward differs. 2. For administrative denials: submit the prior-authorization request through the prescriber's office with complete clinical documentation immediately. 3. For denied PA: file a written internal appeal with Cigna within the stated deadline (typically 180 days from denial), including the full clinical package. 4. Cigna must respond within 30 days (prospective) or 60 days (retrospective). 5. If denied internally, file for IRO external review before the four-month external-review window closes.

## Documentation to Gather

• Diagnosis confirmation: Endocrinology records establishing the Cushing's disease diagnosis — biochemical testing, pituitary imaging, and clinical notes from the managing specialist.
• Prior-treatment history with dates and outcomes: A chronological record of all prior therapies for Cushing's disease — what was used, for how long, and what the result was — as documented in the chart, not just summarized in a letter.
• Clinical severity per the chart: Office notes documenting current signs and symptoms of active hypercortisolism and their functional and health impact.
• Prescriber medical-necessity letter: A structured letter from the treating endocrinologist that maps every Cigna prior-authorization criterion to a specific, dated chart entry. The letter should reference the FDA-approved prescribing information and the applicable endocrinology society guidelines.

## Criteria-Mapping Structure

Obtain Cigna's prior-authorization criteria for Isturisa (request directly from Cigna or find them on Cigna's provider portal). Then create a mapping:

| PA Criterion | Chart Documentation (source, date) | |---|---| | Confirmed diagnosis of Cushing's disease | [Endocrinology note, biochemical confirmation, date] | | Prescribing physician is appropriate specialty | [Prescriber credentials] | | Step-therapy or prior treatment requirement | [Prior agent, dates, outcome per chart] | | Other plan-specific criteria | [Corresponding evidence] |

Attach every referenced record. A complete, criteria-mapped PA submission is significantly less likely to be denied than a general narrative submission, and sets up a strong appeal record if a denial does come.