MOUD Naltrexone LA denied for missing prior authorization 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 Requires Prior Authorization for Long-Acting Naltrexone — and How to Navigate the Appeal

Cigna requires prior authorization (PA) for long-acting injectable naltrexone, meaning the prescription cannot be dispensed without advance approval. If authorization was denied, or if it was never obtained and a retrospective claim was rejected, the appeal path depends on which scenario applies. Either way, the core task is the same: demonstrate that every criterion in Cigna's PA policy is met by documented chart facts.

## Why PA Denials Are Frequently Reversed

PA denials on standard-of-care MOUD medications often result from incomplete submissions — missing documentation, unanswered criteria, or prescriber letters that are too generic. A well-organized resubmission that maps each criterion to a specific chart finding has a high reversal rate. Federal parity law also constrains how burdensome PA requirements can be for substance use disorder treatment relative to comparable medical conditions.

## Your Federal Appeal Rights

• Internal appeal (ERISA §503 / ACA §2719): Submit a formal internal appeal. Cigna must provide the specific criteria used and a full-and-fair review.
• Expedited appeal: If the patient is currently being treated and a gap in medication creates serious clinical risk, request an expedited internal review — Cigna must respond within 72 hours.
• External review (ACA §2719): If internal appeal fails, request IRO review within approximately four months of the original denial. Expedited external review is available for urgent situations.

## Appeal Timeline

1. Request Cigna's PA criteria document for this drug on the day of denial. 2. Gather all documentation (see below) and submit the internal appeal, with expedited flag if clinically appropriate. 3. If denied again, file external IRO review within the statutory window.

## Documentation to Gather

• Diagnosis and severity: Formal OUD or AUD diagnosis with documented severity, including relevant assessment findings from the chart.
• Prior-treatment history: Dates, agents, and outcomes of prior OUD/AUD treatments tried — oral naltrexone, buprenorphine, methadone, behavioral treatment — with documented reasons for transition or failure.
• Clinical rationale for injectable formulation: Prescriber's explanation of why the long-acting injectable form is appropriate (e.g., adherence considerations documented in chart).
• Prescriber PA letter: A detailed letter addressing each PA criterion by name, citing specific chart dates and findings.

## Criteria-Mapping Structure

Obtain Cigna's published PA criteria for long-acting naltrexone. Create a numbered list mirroring each criterion exactly. Under each criterion, provide the chart-sourced evidence that satisfies it (date, note type, finding). Submit this as the primary exhibit. Unaddressed criteria are the most common reason PA appeals fail — answer every one.