TMS denied for missing prior authorization by Cigna?

Cigna's specific coverage criteria for tms 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 Requires Prior Authorization for TMS

Cigna requires prior authorization for TMS because it is classified as a specialized procedure with specific clinical criteria that must be met before coverage is approved. A denial under this reason code typically means either that prior authorization was not obtained before treatment began, or that a prior authorization request was submitted and denied because the documentation did not satisfy Cigna's coverage criteria. If treatment began without authorization, you may still appeal — particularly if the denial causes a retrospective claim to be rejected — but the documentation burden is higher.

## Your Appeal Rights

Under ACA §2719, if you have a non-grandfathered plan, and under ERISA §503 for employer-sponsored plans, you have the right to a full internal appeal. If the internal appeal is denied, you have the right to independent external review by an accredited reviewer outside Cigna. The external review window is typically approximately 180 days from the denial. If the situation is clinically urgent, you may request expedited review. For prospective (prior to treatment) denials, Cigna is required to process urgent prior authorization requests on an expedited timeline.

## What to Gather

• Cigna's coverage criteria document: Request the specific TMS prior authorization criteria and coverage policy from Cigna. Build your appeal around their exact language.
• Prescriber's clinical documentation: A detailed letter from your psychiatrist or treating clinician that addresses every criterion in Cigna's PA requirements point by point.
• Prior treatment history: Documented records of prior antidepressant trials — medication names, doses, duration, and outcomes — sufficient to establish treatment history consistent with Cigna's criteria.
• Diagnosis and severity documentation: Chart notes, validated assessment scores on file, and any functional-impairment documentation.
• Peer-to-peer request: If authorization was denied after submission, ask your prescriber to request a peer-to-peer call with Cigna's medical reviewer before the formal appeal — this often resolves PA denials without a full appeal.

## Criteria-Mapping Structure

For each item in Cigna's prior authorization criteria, provide the matching chart fact:

| Cigna PA Requirement | Supporting Documentation | |---|---| | Qualifying diagnosis | [Chart diagnosis date and clinician] | | Prior medication trials | [Each trial: name, dates, outcome] | | Severity threshold per chart | [Assessment scores on file, clinician severity statement] | | Absence of contraindications | [Prescriber attestation] |

A prior-auth denial is often a documentation problem, not a coverage exclusion. Addressing each criterion specifically and completely is the most direct path to reversal.