Nucala denied for missing prior authorization 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 "Prior Authorization Required" — and How to Resolve It

Nucala (mepolizumab) is a specialty biologic that Cigna requires prior authorization for in virtually all plan designs. A prior-authorization denial typically means the medication was dispensed or administered before authorization was secured, or the authorization request was submitted but did not include all of the clinical documentation Cigna requires. This is a process-driven denial — the underlying medical appropriateness is not necessarily at issue — and it is among the most commonly overturned denial types when the appeal includes complete clinical documentation.

## Your Federal Appeal Rights

• Internal appeal (ACA §2719 / ERISA §503): You are entitled to a full-and-fair review. File within the deadline stated in your denial notice.
• Retrospective authorization appeal: If Nucala has already been administered, request a retrospective authorization review as part of the appeal.
• External review: Available after internal remedies are exhausted, generally within approximately four months of the final adverse determination.
• Expedited review: Available when poorly controlled eosinophilic asthma poses an urgent clinical risk.

## Concrete Appeal Steps

1. Obtain Cigna's current prior-authorization criteria for Nucala from their provider portal or the number on the denial letter. 2. Identify which specific documentation requirement was missing from the original request. 3. Have the prescribing allergist, pulmonologist, or specialist compile a complete authorization package addressing every criterion. 4. Submit as a formal internal appeal, requesting retrospective authorization if the medication has already been administered.

## Documentation to Gather

• Diagnosis confirmation: Specialist-confirmed severe eosinophilic asthma (or applicable indication), ICD-10 coded and chart-supported.
• Eosinophil count: Blood eosinophil value from the lab record — the exact result the prescriber relied on.
• Prior treatment history: Every controller therapy trialed before Nucala, with start/end dates and documented inadequate response.
• Clinical severity: Exacerbation count in the prior year, any hospitalizations or emergency visits, oral corticosteroid use, pulmonary function trends.
• Prescriber medical-necessity letter: Maps the patient's clinical history to each of Cigna's prior-authorization criteria explicitly.

## Criteria-Mapping Structure

Obtain Cigna's prior-authorization criteria for Nucala and the FDA-approved prescribing label. Build a requirement-by-requirement table: each Cigna criterion on the left, the specific chart evidence satisfying it on the right — date of lab result, name and dates of prior therapies as recorded in the chart, exacerbation dates. This format eliminates ambiguity and ensures the reviewer can confirm each requirement is satisfied without having to search the record. Reference the applicable asthma guideline organization generically (e.g., the applicable GINA or specialist society guideline) to support the prescriber's clinical rationale.