Regenerative Injection denied as experimental or investigational by Cigna?

Cigna's specific coverage criteria for regenerative injection 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 Your Regenerative Injection as Experimental

Cigna's experimental or investigational denial means its medical policy team concluded there is insufficient peer-reviewed evidence to classify the specific regenerative injection procedure — platelet-rich plasma (PRP), bone marrow aspirate concentrate, or a related biologic — as proven and effective for your documented diagnosis. Insurers apply their own internal evidence-review framework, which can lag behind current clinical practice and published literature. These denials are among the most commonly appealed and frequently reversed categories, particularly as the evidence base for regenerative procedures continues to grow.

## Your Right to Appeal

• Internal appeal: File a written internal appeal with Cigna within the deadline on your denial letter. Request a copy of the specific medical policy and the clinical evidence review criteria used to reach the denial.
• External review (ACA §2719): After exhausting the internal appeal, you may request independent external review by an IRO. The window is generally up to four months from your final internal denial. Experimental or investigational denials are explicitly eligible for external review under federal law.
• Expedited review: If your condition is urgent, request expedited external review — a decision is typically required within 72 hours.
• ERISA §503: Employer-sponsored plans also carry a full-and-fair review right and the option of federal court review after administrative remedies are exhausted.

## Documentation to Gather

1. Diagnosis and severity records: Physician notes, imaging, and functional assessments documenting the diagnosed condition and why conventional options have been inadequate. 2. Prior treatment history: Dates, treatments, and documented outcomes (or failures) of every standard therapy you have tried, demonstrating that the regenerative injection is not a first-line whim but a considered clinical choice. 3. Published clinical literature: Ask your provider to compile peer-reviewed studies and relevant society position statements supporting use of this injection for your specific diagnosis. Focus on evidence that is current and from recognized medical organizations. 4. Prescriber medical-necessity letter: A detailed letter citing the applicable guideline organization (such as relevant orthopedic, sports-medicine, or pain-medicine society guidelines), explaining the evidence basis, and distinguishing any policy citations Cigna relied on.

## Criteria-Mapping Strategy

Obtain Cigna's medical policy for the specific procedure code billed. Identify every criterion under the "investigational" classification. Map each against your documentation point by point. Pay particular attention to any criterion that references a guideline organization — if your provider's records align with current society guidance, state that alignment explicitly. External reviewers are required to apply current clinical standards, not just the insurer's internal policy, which gives you meaningful recourse when evidence has evolved.