Regenerative Injection denied for missing prior authorization 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 for Prior Authorization

Cigna requires advance prior authorization for regenerative injections before the service is rendered. A prior-auth-required denial means the procedure was performed — or a claim was submitted — without that authorization in place, or the authorization request was submitted but Cigna determined the clinical criteria were not met. For regenerative procedures, Cigna's prior-authorization criteria typically require documented diagnosis, a defined period of conservative treatment, and specific clinical findings. If authorization was simply not obtained before the service, you may still be able to appeal through a retrospective review process, particularly if the service was urgent or authorization requirements were not clearly communicated.

## Your Right to Appeal

• Internal appeal: File a written appeal within the deadline on your denial notice. Distinguish whether the denial is a pure administrative denial (no auth was sought) or a clinical denial (auth was sought but refused). Each has a different appeal strategy.
• External review (ACA §2719): Clinical prior-auth denials — where Cigna concluded medical necessity criteria were not met — are eligible for IRO external review after the internal appeal is exhausted, generally within four months of the final internal denial.
• Expedited review: If the service is still needed urgently, request expedited concurrent review or expedited external review.
• ERISA §503: Employer-sponsored plan members have full-and-fair review rights. Courts have also found that insurers bear responsibility when prior-auth requirements are not clearly disclosed.

## Documentation to Gather

1. Authorization request records: Any documentation showing when and how authorization was requested, what information was submitted, and what response was received. 2. Diagnosis and severity records: Current clinical notes, imaging, and functional assessments establishing the diagnosis and why the procedure was clinically indicated at the time of service. 3. Prior conservative treatment history: A chronological record with dates and outcomes of every conservative approach tried before the regenerative injection. 4. Prescriber medical-necessity letter: A letter from your provider directly addressing Cigna's published prior-authorization criteria for this procedure, confirming that clinical requirements were met at the time of service.

## Criteria-Mapping Strategy

Obtain Cigna's current prior-authorization criteria for the relevant procedure code. List each criterion and document how your clinical situation satisfied it at the time of service. If the denial is purely administrative (no auth obtained), argue for retrospective approval by demonstrating that the clinical criteria were met and that delay would have — or did — cause harm. If Cigna's prior-auth requirements were not clearly communicated in your plan documents, cite that gap as a basis for waiving the administrative denial under applicable state and federal disclosure requirements.