Tumor Genomic Profiling denied as experimental or investigational by Cigna?

Cigna's specific coverage criteria for tumor genomic profiling 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 Denies Tumor Genomic Profiling as Experimental — and How to Appeal

Tumor genomic profiling — including comprehensive genomic sequencing, large multi-gene panels, and liquid biopsy assays — is used by oncologists to identify actionable mutations that guide targeted and immunotherapy treatment decisions. Cigna may classify certain versions of this testing as "experimental, investigational, or unproven" when the specific assay, indication, or tissue type requested falls outside what Cigna's medical coverage policy currently recognizes as established.

### Why This Denial Happens

Cigna's experimental designation is driven by its internal evidence review process. When a specific panel type, specimen source (e.g., liquid biopsy vs. tissue), or cancer indication does not yet meet Cigna's evidentiary threshold for "proven" status under its medical policy, the test is denied as experimental. This does not necessarily reflect the FDA's assessment of the test, the views of professional oncology societies, or the clinical standard of care at major cancer centers. The designation can lag behind the actual state of clinical evidence.

### Why It Is Appealable

The "experimental" label is a coverage determination, not a clinical fact. Appeals succeed when documentation shows that professional society guidelines (such as the applicable NCCN guideline) endorse the test for this indication, that peer-reviewed evidence supports its use, and that the treating oncologist views it as the standard of care for this patient's situation. External reviewers — who are not employed by Cigna — frequently reach different conclusions than internal reviewers on experimental denials.

### Federal Appeal Framework

• Internal appeal: File within the timeframe on your denial notice (typically 180 days for ACA-compliant plans). Cigna must respond within 30 days for pre-service or 60 days for post-service.
• External review (ACA §2719): Experimental or investigational denials are specifically subject to external review rights under the ACA. After internal denial, you have approximately four months to request an independent external review. The IRO's decision is binding on Cigna.
• ERISA §503: Employer-plan enrollees are entitled to a full-and-fair review and may request the full administrative record, including Cigna's internal clinical criteria.
• Expedited review: If a delay would seriously jeopardize health, expedited external review is available — typically decided within 72 hours.

### Documentation to Gather

1. Diagnosis and current clinical status — pathology and staging records confirming cancer type and treatment context. 2. Treating oncologist's medical-necessity letter — a detailed letter from the ordering physician explaining why this specific test is the clinical standard of care for this patient, what actionable information it is expected to produce, and how the result will affect treatment planning. 3. Professional society guideline support — a reference to the applicable NCCN guideline category, ASCO recommendation, or equivalent society guidance that endorses this testing in the patient's clinical scenario. 4. FDA clearance or approval documentation — if the test has FDA clearance or approval, provide documentation; if it is a laboratory-developed test, provide the laboratory's CLIA/CAP certification. 5. Prior treatment and testing history — context showing why this test is necessary now in the course of treatment.

### Criteria-Mapping Structure

Obtain Cigna's current medical coverage policy for the specific test code from cigna.com. The policy will list the specific criteria under which the test is considered "proven" versus "experimental." Build a table mapping each proven-status criterion to the documentation in your patient's chart. If the patient meets criteria that Cigna has listed as established, the experimental denial is directly rebutted. If the clinical situation falls outside those criteria but is supported by professional guidelines, frame the appeal around why Cigna's policy has not kept pace with the evidence.