MOUD Naltrexone LA denied as not medically necessary by Cigna?

Cigna's specific coverage criteria for moud naltrexone la 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 Denies Long-Acting Naltrexone for Medical Necessity — and Why You Can Fight Back

Long-acting injectable naltrexone is an FDA-approved medication for the treatment of opioid use disorder (OUD) and alcohol use disorder (AUD). Cigna's medical-necessity denials on this medication typically reflect a mismatch between the chart documentation submitted and the specific clinical criteria Cigna uses internally. These criteria are drawn from Cigna's own medical coverage policy, and that policy is the document you must obtain and respond to line-by-line.

## Why This Denial Is Appealable

Federal parity law (the Mental Health Parity and Addiction Equity Act) prohibits insurers from applying more restrictive coverage standards to substance use disorder treatment than to analogous medical or surgical care. A bare medical-necessity denial on a standard-of-care MOUD medication is a strong candidate for a parity-based challenge. Major addiction medicine organizations — including ASAM and the American Academy of Addiction Psychiatry — recognize long-acting naltrexone as a first-line treatment option. Your prescriber's clinical judgment, backed by chart documentation, is the cornerstone of the appeal.

## Your Federal Appeal Rights

• Internal appeal (ERISA §503 / ACA §2719): You have the right to a full-and-fair internal review. Cigna must give you written notice of its criteria and the specific reason for denial. Request the complete claim file and the coverage policy citation used.
• External review: After exhausting internal appeals (or if Cigna misses its deadline), you may request an Independent Review Organization (IRO) review under ACA §2719. The standard window is approximately four months from the denial date. An expedited external review is available when your health is at serious risk — request it in writing immediately if that applies.

## Appeal Timeline

1. Request the denial letter, the claim file, and Cigna's applicable coverage policy in writing on the day of denial. 2. Submit your internal appeal within the timeframe stated on the denial letter (often 180 days). 3. If denied again or if Cigna misses its response deadline, file for external IRO review within the statutory window.

## Documentation to Gather

• Diagnosis confirmation: Chart entries, ICD codes, and structured assessment tools documenting OUD or AUD severity.
• Prior-treatment history: Dates, agents, doses (from the chart), and documented outcomes or intolerances for any prior medications or behavioral treatments.
• Clinical severity: Most recent assessments of functional impairment, craving, relapse history, and any co-occurring conditions.
• Prescriber letter: A detailed medical-necessity letter that explains why long-acting naltrexone is appropriate for this patient, referencing the applicable ASAM or other guideline organization and citing chart facts.

## Criteria-Mapping Structure

Obtain Cigna's published coverage policy for MOUD/long-acting naltrexone. For each listed criterion, create a two-column table: left column states the requirement verbatim; right column cites the specific chart date, note, or test result that satisfies it. Submit this mapping as an exhibit. If any criterion is ambiguous, ask Cigna in writing to clarify what evidence would satisfy it — this creates a record for the external reviewer.