Trelegy denied for missing prior authorization by Cigna?

Cigna's specific coverage criteria for trelegy 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 Trelegy

Trelegy Ellipta is a branded triple-combination inhaled therapy for COPD or asthma, and Cigna — like most major insurers — places it in a tier that requires prior authorization (PA) before dispensing. PA is not a denial of the drug itself; it is a gate requiring clinical documentation that your specific situation meets Cigna's coverage criteria before the claim is paid. The most common reason a PA is denied on first submission is insufficient documentation rather than a genuine clinical disagreement.

## Why a PA Denial Is Appealable

Cigna's PA criteria must be grounded in evidence-based clinical standards. If your physician believes Trelegy is medically necessary and your chart supports that conclusion, a denial is challengeable. The appeal process allows you to submit the clinical record that the initial PA submission may have lacked.

## Your Federal Appeal Rights

• Internal appeal: Submit a formal appeal with supporting clinical documentation. Cigna must issue a decision within the regulatory deadline — sooner for urgent cases.
• External review (ACA §2719): After exhausting the internal appeal, you may request independent external review, typically within about four months of the original denial. The IRO's decision is binding.
• ERISA §503: Employer-sponsored plan members are entitled to a full-and-fair review and access to all plan documents used in the decision.
• Expedited review: If your condition is acute or you face rapid deterioration, request expedited PA appeal — decisions are generally required within 72 hours.

## Documentation to Gather

• Diagnosis records: Physician notes confirming a diagnosis of COPD or asthma with documented severity.
• Treatment history: A complete list of previously tried inhaled therapies — include the drug name, dates of use, and why each was discontinued (inadequate response, side effects, or contraindication).
• Spirometry or objective testing: Lung function data in the chart that supports the severity level justifying triple therapy.
• Prescriber medical-necessity letter: Your physician should write a letter explaining why Trelegy is specifically required, referencing applicable guidelines from organizations such as GOLD (for COPD) or GINA (for asthma), and why alternatives are insufficient.
• Cigna's PA criteria: Request the exact PA criteria Cigna applied; you are entitled to this under ERISA or state law.

## Criteria-Mapping Structure

Obtain Cigna's published PA criteria for Trelegy or the relevant drug class. Then map each criterion to a specific chart document:

| Cigna PA Criterion | Supporting Chart Evidence | |---|---| | [Criterion 1 — e.g., diagnosis confirmed] | Chart note date + physician statement | | [Criterion 2 — e.g., prior therapy tried] | Medication list with dates and outcomes | | [Criterion 3 — e.g., severity documented] | Spirometry report or clinical severity notation |

This side-by-side map is the most effective tool for an appeal reviewer to confirm each box is checked.