Myfembree denied as duplicate or overlapping therapy by Cigna?

Cigna's specific coverage criteria for myfembree 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 Myfembree as "Duplicate Therapy" — and Why You Can Appeal

Myfembree (relugolix, estradiol, and norethindrone acetate) is an FDA-approved oral combination therapy for moderate to severe pain associated with endometriosis in premenopausal women, and for heavy menstrual bleeding associated with uterine fibroids. A "duplicate therapy" denial from Cigna typically means the plan determined that another drug already on your profile covers the same clinical indication. This rationale is often incorrect or incomplete: Myfembree's specific hormonal combination and mechanism of action are distinct from other hormonal therapies, and if prior agents produced inadequate control or intolerable side effects, duplication is not the clinically accurate characterization.

## The Federal Appeal Framework

• Internal appeal (Level 1): File a written appeal within Cigna's deadline (typically 180 days from the denial). Cigna must issue a decision within 30 days for pre-service non-urgent requests or 60 days for post-service claims.
• Expedited review: If symptoms are severe or the delay would cause harm, request expedited internal review; a decision is required within 72 hours.
• External review (ACA §2719): After a final internal denial, you may request independent external review — generally within 4 months. An accredited IRO will assess whether the "duplicate therapy" characterization is clinically sound.
• ERISA §503: Employer-sponsored plan members are entitled to a full-and-fair review with a specific rationale for the duplicate finding.

## Documents to Gather

1. Prior therapy history: A detailed list of all hormonal therapies previously tried, with start and stop dates, doses used, reasons for discontinuation (inadequate efficacy, side effects, contraindications), and the physician's clinical assessment of each outcome. 2. Diagnosis documentation: Records confirming the underlying diagnosis (endometriosis-associated pain or fibroid-associated heavy menstrual bleeding) and its severity per your chart. 3. Prescriber medical-necessity letter: A letter from your gynecologist or specialist explaining how Myfembree is clinically distinct from the therapy Cigna identified as duplicative, and why that therapy does not adequately address your condition. 4. FDA prescribing label: The Myfembree prescribing information confirms its approved indications and specific formulation. Ask your physician to demonstrate that the "duplicate" drug is not therapeutically equivalent for your specific indication. 5. Cigna's coverage policy: Obtain the specific policy Cigna applied and confirm which drug they identified as the alleged duplicate.

## Criteria-Mapping Structure

In your appeal, create a side-by-side comparison showing:

• Drug identified as duplicate — mechanism of action, approved indications, patient's history with that drug, and reason it is inadequate or was discontinued.
• Myfembree — mechanism of action, approved indication as stated in the FDA prescribing label, and how it addresses the clinical gaps left by the prior therapy.

Close with a clear statement that two therapies are not duplicative when a patient has tried and failed (or cannot tolerate) the first, or when their mechanisms and formulations are clinically distinct for this patient's documented condition.