IVF denied for missing prior authorization by Cigna?

Cigna's specific coverage criteria for IVF 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 Your IVF for Missing Prior Authorization

Cigna requires prior authorization for IVF before the cycle begins in virtually all plans that cover the procedure. A "prior authorization required" denial means Cigna did not have an approved PA on file at the time the service was rendered or billed. This can result from an authorization request that was never submitted, a request that was submitted but not approved before the cycle started, an administrative gap between your provider's office and Cigna, or a situation where the provider reasonably but incorrectly assumed coverage was in place.

## Why This Denial Is Appealable

Retroactive authorization can be granted when the clinical criteria for approval were met at the time of service, even if the paperwork was not in order. If your provider made a good-faith effort to obtain authorization and experienced an administrative failure on Cigna's end, that supports the appeal. If the PA was submitted and Cigna failed to respond within the required timeframe, that too is grounds for reversal. Most importantly, if IVF was medically necessary and you would have qualified for authorization, the procedural defect should not override your underlying benefit entitlement.

## Federal Appeal Framework

• Internal appeal: File under ERISA §503 or applicable state law within the timeframe on your denial letter — typically 180 days. Request the specific PA criteria Cigna applies to IVF and any documentation of what occurred with your original submission.
• External review: Under ACA §2719, escalate to an independent review organization if the internal appeal is denied. File within four months of the final internal denial. IROs can evaluate both the procedural and clinical aspects of the denial.
• Expedited review: If future cycles are at risk due to fertility timing, your physician can request expedited review to prevent further harm from delay.

## Documentation to Gather

• PA submission evidence: Fax confirmation sheets, provider portal screenshots, call logs with reference numbers, or any other documentation that a PA request was made.
• Timeline of provider-Cigna communications: A chronological record from your provider's office of all contacts with Cigna regarding authorization.
• Clinical records supporting eligibility: Full documentation showing that at the time of service, you met Cigna's medical-necessity criteria for IVF — making retroactive approval appropriate.
• Medical-necessity letter: A letter from your reproductive endocrinologist confirming that IVF was medically necessary and that the clinical criteria for authorization were met.
• Plan disclosure documents: Review your Summary Plan Description for how the PA requirement is described; if it was not clearly disclosed or the process was ambiguous, note that in the appeal.

## Criteria-Mapping Structure

Request Cigna's prior authorization criteria for IVF. For each clinical criterion, provide the matching chart documentation showing eligibility at the time of service. Separately, document the administrative timeline showing any good-faith effort to obtain PA. If Cigna failed to act on a submitted request within the required regulatory timeframe, cite the applicable plan or regulatory deadline. A two-part appeal — clinical eligibility plus procedural good faith — is the strongest structure for a retroactive authorization appeal.