IVF denied for failing step therapy 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's Step-Therapy Requirement Is Blocking IVF — and How to Fight It

Cigna's step-therapy denial means the plan requires documented failure of one or more less intensive fertility treatments — such as ovulation induction with oral medications, intrauterine insemination (IUI), or injectable gonadotropin cycles — before it will authorize IVF. This is sometimes called a "fail-first" requirement. The rationale is cost management; the medical counter-argument is that step-therapy protocols are population-level defaults that do not account for individual clinical factors that make lower-intensity treatments futile or harmful.

## Why This Denial Is Appealable

Step-therapy denials are overturned when the clinical record shows one of the following: you have already completed the required prior steps and those records were not submitted with the initial request; your diagnosis makes the required prior steps medically inappropriate (for example, severe tubal factor, severe male-factor infertility, or a genetic indication requiring preimplantation genetic testing); or your reproductive endocrinologist concludes that requiring additional steps would cause clinically meaningful delay that worsens prognosis. The American Society for Reproductive Medicine (ASRM) publishes guidance on when IVF is the appropriate first-line or preferred treatment — your physician should cite this organization specifically.

Many states also have infertility mandate laws that restrict how insurers may apply step-therapy to IVF. Ask your physician's office or a patient advocate to check whether your state's mandate applies to your plan type.

## Your Federal Appeal Rights

• Internal appeal — submit a written internal appeal within 180 days of the denial notice. Pre-service appeals generally require a decision within 30 days.
• External review (ACA §2719) — after exhausting internal appeals, request independent external review. You typically have four months from the final internal denial. The IRO's decision is binding.
• Expedited review — available when your physician certifies that delay would seriously jeopardize your health. Response required within 72 hours.
• ERISA §503 — applies to employer self-funded plans; full-and-fair review rights and federal court access are available if internal and external remedies are exhausted.

## What to Gather

• Prior-treatment records — documentation of every prior infertility treatment attempted, including dates, medications used, monitoring results, cycle outcomes, and the clinical reason each cycle ended.
• Diagnosis records — reproductive endocrinology notes documenting the specific diagnosis that drives the IVF recommendation, particularly any factor that makes lower-intensity treatment unlikely to succeed.
• Specialist step-therapy exception letter — your physician should address each step Cigna's policy requires, either confirming it was completed or explaining why it is contraindicated or clinically inappropriate in your case.
• Cigna's coverage policy — pull the current published policy and identify every step-therapy criterion. Map each one to your records.

## Criteria-Mapping Structure

For each step Cigna's policy lists as a prerequisite, create a two-column table: the exact policy requirement in the left column, and the chart fact or physician attestation that satisfies or waives it in the right column. If your physician is asserting a clinical exception to any step, the medical-necessity letter must state the ASRM-recognized basis for that exception explicitly.