Myfembree denied for failing step 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 Requires Step Therapy for Myfembree — and How to Appeal

Myfembree (relugolix/estradiol/norethindrone acetate) is an FDA-approved once-daily oral therapy for heavy menstrual bleeding from uterine fibroids and for endometriosis-associated pain. Cigna's step-therapy (also called "fail-first") policy requires that a plan member try and document an inadequate response to one or more preferred or lower-cost alternatives before Myfembree will be covered. When that prior-step documentation is missing from the pharmacy submission, the claim is automatically denied.

### Why This Denial Is Appealable

Step-therapy denials are frequently reversed on appeal — particularly when a patient has already tried prior-step medications, experienced adverse effects, or has a clinical reason why those alternatives are contraindicated or inappropriate. Many states have enacted step-therapy reform laws that require commercial insurers to grant a step-therapy exception when a patient has previously tried the required therapy, when the required therapy is clinically contraindicated, or when the required therapy is expected to cause serious harm. Even in states without such a law, federal parity and full-and-fair review requirements under ERISA Section 503 and ACA Section 2719 apply.

### Your Appeal Timeline

• Internal appeal: File within the window stated on your denial notice (often 180 days). Pre-service internal appeals must be decided within 30 days; post-service within 60 days.
• External review: After an adverse internal decision, you typically have four months to request independent external review. The external reviewer's determination is binding on Cigna.
• Expedited track: Available when standard timing would seriously jeopardize your health or ability to regain maximum function. Request in writing; decision required within 72 hours.

### Documentation to Gather

1. Diagnosis confirmation — clinical notes, ultrasound, or surgical/pathology reports establishing uterine fibroids or endometriosis. 2. Prior-therapy history — for each step-therapy drug Cigna requires, provide dates of trial, the doses used (from chart notes), objective or subjective response, and the reason for stopping or switching. 3. Adverse effects or contraindication documentation — if a required step drug was not tolerated or was clinically inappropriate, include the chart entries and any relevant lab results. 4. Prescriber medical-necessity letter — a detailed letter from your provider explaining why the prior-step alternatives are inadequate for your specific clinical situation and why Myfembree is medically necessary now.

### Criteria-Mapping Structure

Request Cigna's published step-therapy policy for Myfembree in writing. Also obtain the FDA-approved prescribing information for Myfembree. Build a response document with one row per requirement in Cigna's policy. For each requirement, state the requirement verbatim, then provide the precise chart fact that satisfies it (with exhibit references). If a required step drug was tried, record the trial dates and outcomes. If a step was skipped for clinical reasons, document those reasons explicitly. Your prescriber's attestation that the prior steps were tried or are inappropriate is the single most important piece of evidence in a step-therapy appeal. Attach relevant guideline organization recommendations (e.g., from the applicable ACOG or AAGL guideline) that support Myfembree as an appropriate therapy for your diagnosis.