Rystiggo MG denied for missing prior authorization by Cigna?

Cigna's specific coverage criteria for rystiggo mg 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 Rystiggo (rozanolixizumab-noli) for Missing Prior Authorization — and Why You Can Appeal

Cigna requires prior authorization for specialty biologics, including Rystiggo for generalized myasthenia gravis (gMG), before dispensing or administering the drug. A prior-authorization denial means either that no authorization request was submitted before treatment, that the request was submitted but not approved before the claim was filed, or that the authorization request was denied for an underlying clinical reason. Each scenario has a distinct appeal path. Procedural prior-auth denials — where the drug would have been approved clinically but authorization was not obtained — are among the most commonly reversed denial types, particularly when the prescribing team can demonstrate the clinical criteria were met at the time of prescribing.

## Your Appeal Rights

Under ACA Section 2719, non-grandfathered plans must provide independent external review after internal appeals. ERISA Section 503 requires a full-and-fair review with written reasoning. If the underlying PA denial was based on a clinical determination (not merely a procedural omission), you have the same full appeal rights as a medical-necessity denial. Expedited processing is available if your gMG is in exacerbation, crisis, or is otherwise urgent — Cigna must respond within a significantly shorter timeframe than the standard track. The external review window is generally available for roughly four months after internal remedies are exhausted.

## The Appeal Process and Timeline

1. Determine whether the denial is purely procedural or clinical: if no PA was submitted, the fastest path is often a retrospective authorization request accompanied by a clinical justification letter, filed simultaneously with the internal appeal. 2. File a first-level internal appeal within the timeframe stated on the denial (often 180 days). 3. If the PA request was submitted and denied on clinical grounds, treat the appeal as a medical-necessity appeal and follow that documentation approach. 4. If denied internally, escalate to external review. Request peer-to-peer review between the treating neurologist and Cigna's medical director in parallel — this is often the fastest resolution path for specialty drug PA denials.

## Documentation to Gather

• Cigna's prior-auth criteria for Rystiggo: download the current criteria from Cigna's provider portal and map the patient's chart to each requirement before submitting.
• Diagnosis and antibody status confirmation: records confirming gMG, anti-AChR or anti-MuSK antibody positivity, and disease severity classification.
• Prior treatment history: a chronological account of all prior gMG therapies — with dates, duration, documented response, and reason for each change — to demonstrate the patient has completed any required therapeutic steps.
• Clinical severity documentation: objective functional and respiratory assessments from the chart showing the impact of disease activity and the urgency of effective treatment.
• Neurologist medical-necessity letter: a detailed letter from the treating neurologist addressing each of Cigna's PA criteria for Rystiggo specifically, explaining why the patient meets the criteria and why Rystiggo is the appropriate next step in treatment.
• Proof of authorization submission: if a PA was submitted and lost or improperly processed, obtain date-stamped proof of submission (portal confirmation, fax receipt, call log).

## Criteria-Mapping Structure

Obtain Cigna's current prior-authorization criteria for Rystiggo from the provider portal. Build a two-column table: each PA criterion on the left, the specific chart fact or document satisfying it on the right. Address every criterion — even those the patient clearly meets — because reviewers note omissions and may use them to justify continued denial. Include the FDA-approved prescribing label's indicated population in a parallel column to show that Cigna's PA criteria are consistent with (and not broader than) the label.