TMS denied for failing step therapy 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's Step-Therapy Protocol Blocks TMS Coverage

Cigna's step-therapy (also called "fail-first") requirement for TMS means the plan requires you to demonstrate that you have tried and failed a specified number of antidepressant medications — and potentially other treatments — before TMS will be covered. A denial under this reason means Cigna believes the documented treatment history in your file does not satisfy their step criteria, either because the number of trials is insufficient, the trials were not of adequate dose or duration, or the documentation in the claim did not capture the full treatment history.

This is one of the most commonly overturned denial reasons because the evidence is often present in the chart but was simply not submitted with the original prior-authorization request.

## Your Appeal Rights

Under ACA §2719 and ERISA §503, you are entitled to a full internal appeal and, if denied, an independent external review by an accredited reviewer with no financial relationship to Cigna. The standard external review window is approximately 180 days from the denial. If waiting would seriously jeopardize your health, you may request expedited review. Additionally, many states have step-therapy override laws that require insurers to grant exceptions when specific clinical conditions are met — check whether your state's law applies to your plan.

## What to Gather

• Complete medication history: A comprehensive, chronological list of every antidepressant and relevant psychiatric medication you have tried, with start and stop dates, prescribing clinicians, and documented outcomes or reasons for discontinuation. Pharmacy records, medication reconciliation notes, and prior provider records are all useful.
• Documentation of adequate trials: Evidence that each prior medication was taken at an appropriate dose for an appropriate duration — this is what Cigna's criteria require, and your chart or prescriber letter must address it explicitly.
• Reason for step exceptions: If any medication on Cigna's required step list is contraindicated for you, caused serious adverse effects, or was tried and failed, document this specifically.
• Prescriber medical-necessity letter: Your psychiatrist should write a letter addressing each of Cigna's step-therapy requirements directly and explaining why TMS is now the medically appropriate next step.

## Criteria-Mapping Structure

Request Cigna's step-therapy criteria and map each required step to your documented history:

| Cigna Step Requirement | Chart Evidence Satisfying It | |---|---| | Step 1 medication trial | [Medication, dates, dose, outcome] | | Step 2 medication trial | [Medication, dates, dose, outcome] | | Additional steps per policy | [Continue for each required step] | | Exception basis (if applicable) | [Adverse effect, contraindication, or clinical reason documented] |

If your medication history satisfies the criteria but was simply not captured in the initial request, a well-documented appeal with complete pharmacy and chart records has a high likelihood of reversal.