Nucala denied as not medically necessary by Cigna?

Cigna's specific coverage criteria for nucala 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 Nucala for "Medical Necessity" — and How to Build a Winning Appeal

Nucala (mepolizumab) is a targeted anti-IL-5 biologic indicated for severe eosinophilic asthma and certain other eosinophilic conditions. Medical-necessity denials from Cigna for Nucala almost always come down to one of three documentation gaps: the eosinophil count was not clearly documented in the submitted record; the patient's history of inadequate response to prior standard therapy was not sufficiently detailed; or the clinical picture did not convey the severity and uncontrolled nature of the disease. None of these gaps means the drug is inappropriate — they mean the appeal must reconstruct the clinical story more completely.

## Your Federal Appeal Rights

• Internal appeal (ACA §2719 / ERISA §503): You have the right to a full-and-fair review. File within the deadline on your denial notice.
• External review: After internal remedies are exhausted, request IRO review. The window is generally within approximately four months of the final adverse determination. External reviewers apply the standard of care, not just Cigna's internal policy.
• Expedited review: Available if poorly controlled asthma is causing frequent exacerbations or hospitalizations.

## Concrete Appeal Steps

1. Obtain Cigna's current published coverage criteria for Nucala — identify every criterion the denial says was not met. 2. Have the prescribing allergist or pulmonologist review the denial letter and write a targeted response. 3. Pull all relevant lab results, pulmonary function tests, and exacerbation records from the chart. 4. Submit a formal internal appeal package with the clinical letter and complete supporting documentation.

## Documentation to Gather

• Diagnosis confirmation: Specialist-confirmed severe eosinophilic asthma (or applicable indication) with supporting ICD-10 coding.
• Eosinophil documentation: Blood eosinophil count from the chart — the exact value the prescriber relied upon (obtain from the lab report, not from this commentary).
• Prior treatment history: Every controller medication tried, with start dates, end dates, doses as charted, and the documented reason for inadequacy.
• Clinical severity: Exacerbation frequency in the past year, any emergency visits or hospitalizations, oral corticosteroid courses, spirometry trends.
• Prescriber medical-necessity letter: A detailed letter mapping the patient's history to each of Cigna's published criteria.

## Criteria-Mapping Structure

Obtain both Nucala's FDA-approved prescribing information and Cigna's coverage policy. Create a requirement-by-requirement table: each criterion on the left, the specific chart evidence on the right — date of lab result, date of exacerbation, name and dates of prior therapy as recorded in the chart. Reference the applicable asthma guideline organization generically (e.g., the applicable GINA or specialist society guideline) to support that this treatment approach aligns with the recognized standard of care.