Tumor Genomic Profiling denied as not medically necessary 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 on Medical-Necessity Grounds — and How to Appeal

Tumor genomic profiling — including comprehensive genomic sequencing, multi-gene panels, and liquid biopsy testing — identifies the specific molecular alterations driving a patient's cancer, enabling oncologists to select targeted therapies and immunotherapies with the greatest likelihood of benefit. Cigna may issue a medical-necessity denial when the clinical documentation submitted at the time of the prior authorization request does not clearly establish that the patient meets all the criteria in Cigna's medical coverage policy for the requested test.

### Why This Denial Happens

Medical-necessity denials on genomic profiling typically occur because the submitted documentation was incomplete, did not address one or more of Cigna's stated coverage criteria, or was reviewed by a Cigna medical director who concluded that the clinical circumstances do not meet the policy threshold. Common gaps include insufficient documentation of cancer type and stage, absence of a clear explanation of how test results will change management, or failure to demonstrate that the patient has an indication recognized in Cigna's policy. These are documentation problems as much as clinical ones, and they are highly correctable on appeal.

### Why It Is Appealable

A medical-necessity denial must be based on Cigna's published criteria. If the patient actually meets those criteria and the documentation now reflects that, the denial is directly reversible. Even if the case is arguable, you are entitled to an independent clinical review — and external reviewers applying the same criteria often reach different conclusions.

### Federal Appeal Framework

• Internal appeal: File within the timeframe on the denial notice (typically 180 days for ACA-compliant plans). Cigna must decide within 30 days for pre-service or 60 days for post-service appeals.
• External review (ACA §2719): After an adverse internal decision, you have approximately four months to request independent external review by an IRO. The IRO's decision is binding on Cigna.
• ERISA §503: Employer-plan enrollees are entitled to a full-and-fair review and may compel production of the complete administrative record, including the criteria applied and the reviewing physician's rationale.
• Expedited review: Available when delay would seriously jeopardize health; decisions are generally required within 72 hours.

### Documentation to Gather

1. Diagnosis confirmation — current pathology report, including cancer type, histology, and stage at the time of the request. 2. Clinical indication for testing — chart notes clearly documenting the specific clinical question the test is intended to answer (e.g., selection of targeted therapy, eligibility for a clinical trial, determination of prognosis). 3. Treatment history — records of prior systemic therapies with dates, responses, and outcomes, establishing context for why genomic information is needed at this point in care. 4. Ordering oncologist's medical-necessity letter — a signed, detailed letter explaining why this patient, at this stage, requires comprehensive genomic profiling; what actionable information is expected; and how results will directly affect the treatment plan. 5. Applicable guideline reference — citation of the relevant NCCN guideline category or equivalent professional society recommendation supporting testing in this clinical scenario.

### Criteria-Mapping Structure

Download the current Cigna medical coverage policy for the specific test code at cigna.com. Extract every listed coverage criterion. For each criterion, identify the exact chart record, note date, or test result that satisfies it. Submit this as a structured exhibit attached to your appeal letter. A criterion-by-criterion response converts a vague narrative appeal into a reviewable document and makes it far more difficult for Cigna to sustain the denial without specifically explaining which criterion the patient fails to meet.