Regenerative Injection denied as not medically necessary 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 Not Medically Necessary

A medical-necessity denial from Cigna means that, based on the clinical information submitted with the prior-authorization or claim, the reviewer concluded that the regenerative injection does not meet Cigna's coverage criteria for your specific diagnosis, condition severity, or treatment history. This is the most common denial type for regenerative procedures. It does not mean your provider made a wrong clinical judgment — it typically means the documentation submitted was incomplete, did not address Cigna's specific criteria, or did not clearly establish that conventional treatments were tried and failed.

## Your Right to Appeal

• Internal appeal: Submit a written internal appeal within the timeframe on your denial letter. Request the specific medical policy and clinical criteria applied. Cigna is required to provide these.
• External review (ACA §2719): If the internal appeal is denied, you may request IRO external review — generally within four months of your final internal denial. An independent clinician, not employed by Cigna, will review your case against current medical standards.
• Expedited review: Available if your condition is urgent; a decision is typically required within 72 hours.
• ERISA §503: Applicable to employer-sponsored plans, providing full-and-fair review rights and federal court access after exhaustion.

## Documentation to Gather

1. Diagnosis confirmation: Current clinical notes, imaging, and specialist findings establishing the specific diagnosis and which anatomical structure is affected. 2. Severity documentation: Functional assessments, pain records, physical therapy notes, and any validated outcome measures your provider has used — these demonstrate that the condition is clinically significant, not mild or self-limiting. 3. Step-therapy history: A chronological list of every conservative treatment attempted (physical therapy, NSAIDs, corticosteroid injections, bracing), with start/stop dates and documented response. Cigna's medical policy for regenerative injections almost always requires prior conservative care. 4. Prescriber medical-necessity letter: A letter from your treating clinician that directly addresses each of Cigna's published criteria, explains why the regenerative injection is the appropriate next step, and cites the applicable clinical guideline organization supporting this approach.

## Criteria-Mapping Strategy

Download the current version of Cigna's medical policy for your specific procedure. List every coverage criterion — diagnosis requirements, prior-treatment requirements, clinical-severity requirements, and any documentation requirements. For each criterion, write a one-sentence response citing the exact chart entry, date, and clinician that satisfies it. Submit this as a structured exhibit alongside your appeal. Reviewers — including IRO clinicians — respond well to a clear point-by-point demonstration that every box is checked.