Regenerative Injection denied for failing step therapy 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 Under Step Therapy

Cigna's step-therapy protocol requires that you try and document failure of one or more specified conservative treatments before approving a regenerative injection. This is sometimes called a "fail-first" or "step-edit" requirement. The denial does not mean the injection is inappropriate — it means Cigna's policy requires a documented treatment history before it will authorize the more advanced intervention. These denials are frequently resolved on appeal when complete treatment records are submitted, when the required steps were in fact completed but not included in the original submission, or when a prescriber documents a clinical reason why the required steps are contraindicated or have been exhausted.

## Your Right to Appeal

• Internal appeal: File a written appeal within the deadline on your denial letter. Request the specific step-therapy protocol Cigna applied — the exact sequence, duration, and documentation requirements for each required step.
• External review (ACA §2719): If the internal appeal fails, IRO external review is available — generally within four months of the final internal denial. Many states have also enacted step-therapy reform laws that create additional protections, including override rights when steps were tried, are contraindicated, or would cause clinically significant delay.
• Expedited review: Available for urgent conditions.
• ERISA §503: Employer-sponsored plan members retain full-and-fair review rights.

## Documentation to Gather

1. Completed step documentation: A chronological record — with dates, providers, and documented outcomes — for every conservative treatment you have undergone. This is the most important document in a step-therapy appeal. Each step should be matched explicitly to Cigna's required sequence. 2. Reason for step failure or inapplicability: If a required step was not completed because it was contraindicated, previously tried under a different insurer, or produced a documented adverse outcome, your prescriber should state this clearly and in writing. 3. Diagnosis and severity records: Current clinical notes and imaging establishing the diagnosis and the clinical urgency of moving to the regenerative injection. 4. Prescriber medical-necessity letter: A letter from your treating clinician addressing each required step, confirming which were completed and why any incomplete steps are not appropriate, and citing the applicable clinical guideline organization supporting the proposed treatment.

## Criteria-Mapping Strategy

Obtain the complete step-therapy protocol from Cigna's published medical policy. List every required step — the treatment type, required duration or number of sessions, and documentation required to demonstrate failure. For each step, cite the specific chart entry, date, and provider that satisfies it. If you have already completed all required steps and this documentation was simply missing from the initial authorization request, make that the centerpiece of your appeal. If you are seeking a step-therapy override, explicitly invoke both the applicable state step-therapy override law (if your state has one) and the ACA's requirement that coverage restrictions not prevent access to medically necessary care.