Cigna · MOUD Naltrexone LA · US health-plan appeal rights

MOUD Naltrexone LA denied for failing step therapy by Cigna?

Q: How long do I have to appeal a Cigna MOUD Naltrexone LA denial?

Internal appeal window: Typically 180 days from the denial date. External review window: Typically 60–120 days after the final internal denial. The clock starts from the date on the denial letter.

Step-therapy denials usually flip when the appeal documents that prior alternatives were tried and failed, or were contraindicated, or aren't safe for the patient.

By Michael John Ryan, Founder & Privacy Officer, DenialHelp, LLC

Last reviewed 2026-05-10

Policy data current as of 2026-04-26

US health-plan appeal rights

Cite: Most US health plans have appeal rights under either the ACA, ERISA, or Medicare/Medicaid rules

Most US health plans are required by federal law to give you both an internal appeal (where the insurer reconsiders) and an external review (where an independent reviewer decides). The exact timelines and processes depend on what kind of plan you have — marketplace / employer group, self-funded, Medicare Advantage, or Medicaid MCO — but in every case there's a window after the denial during which you have the right to fight it.

Internal appeal window

Typically 180 days from the denial date

External review window

Typically 60–120 days after the final internal denial

What Cigna typically requires

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.

Source policy: Cigna / Evernorth BH SUD Treatment Coverage Policy + Vivitrol/Sublocade MAT policies

The Cigna angle on MOUD Naltrexone LA

## Why Cigna Uses Step Therapy for Long-Acting Naltrexone — and How to Override It

Step therapy (also called 'fail-first') requires that a patient try one or more preferred medications before Cigna will authorize long-acting injectable naltrexone. For OUD and AUD treatment, this frequently means demonstrating a trial of an oral formulation or another MOUD. If your prescriber has determined that step medications are clinically inappropriate or have already been tried, you have a strong basis for a step-therapy exception.

## Why Step-Therapy Denials on MOUD Are Frequently Overturned

Many states have enacted step-therapy exception laws that require insurers to grant exceptions when a required step drug was previously tried and failed, causes or is reasonably expected to cause an adverse reaction, or is otherwise clinically contraindicated. Even in states without explicit step-therapy laws, ERISA and ACA internal appeal rights apply. Parity law further constrains step requirements on SUD medications. A prescriber's documented clinical judgment that step drugs are inappropriate is entitled to meaningful weight.

## Your Federal Appeal Rights

Step-therapy exception / internal appeal (ERISA §503 / ACA §2719): File a step-therapy exception and a formal internal appeal simultaneously. Request Cigna's step-therapy criteria document in writing.
External review (ACA §2719): After exhausting internal options, request IRO review within approximately four months of the original denial. Expedited review is available if treatment delay creates serious health risk.

## Appeal Timeline

1. On the denial date, request Cigna's step-therapy criteria and the full claim file. 2. Document whether any required step drug has been tried (with outcomes) or is clinically inappropriate. 3. Submit the step-therapy exception request and internal appeal with the documentation below. 4. If denied, file for external IRO review within the statutory window.

## Documentation to Gather

Prior step-drug history: Dates, agents, documented outcomes, and reasons for discontinuation or failure of each step medication, pulled directly from the chart.
Clinical rationale for skipping steps: Prescriber's written explanation of why each required step drug is inappropriate for this patient — referencing chart findings, not general assertions.
Diagnosis and severity: Documentation supporting the urgency or severity of the condition that informs the prescribing decision.
Applicable ASAM guidance: Reference to the relevant addiction medicine guideline organization's recognition of long-acting naltrexone as a first-line option (cite the organization, not statistics).
State exception law: If your state has a step-therapy exception statute, cite it by name in the appeal letter.

## Criteria-Mapping Structure

Obtain Cigna's step-therapy exception criteria. Build a two-column table: left column states each step requirement; right column documents whether the step was completed (with chart date and outcome) or why an exception applies. Submit this as the lead exhibit. An unaddressed step is the most common reason these appeals fail — account for every required step explicitly.

Next steps

Find the date on the denial letter — your appeal window starts there.
Read your plan's Summary of Benefits and Coverage (SBC) for the specific deadlines.
Request the insurer's claim file in writing — they must provide it.
Submit your appeal in writing with new clinical evidence and a physician statement.

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Related appeal guides

Other Cigna appeals

Other denial reasons for Cigna MOUD Naltrexone LA

denied as not medically necessary denied as non-formulary denied for missing prior authorization denied as experimental or investigational denied as not FDA-approved for this use

This guide describes general US federal appeal rights based on Most US health plans have appeal rights under either the ACA, ERISA, or Medicare/Medicaid rules. Your specific plan documents (Summary of Benefits and Coverage, Evidence of Coverage) override anything here. DenialHelp is not your lawyer and not your physician — we draft appeal letters that your physician signs. Outcomes depend on your insurer's decision and factors outside our control. Reviewed by Michael John Ryan on 2026-05-10. Editorial standards: denialhelp.com/authors.