Tumor Genomic Profiling denied for missing prior authorization 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 Requires Prior Authorization for Tumor Genomic Profiling — and How to Navigate or Appeal a Denial

Tumor genomic profiling — including comprehensive genomic sequencing and large multi-gene panels — is a high-cost diagnostic service that Cigna subjects to prior authorization review. When a claim is denied because prior authorization was not obtained, or when a prior authorization request is denied, the path forward depends on which situation you are in.

### Why This Denial Happens

Prior-authorization denials on genomic testing occur in two distinct scenarios. The first is a claim denial for a test that was performed without authorization — in that case, the clinical merit of the test does not matter initially; the procedural barrier must be addressed. The second is a denial of the prior authorization request itself, meaning Cigna reviewed the clinical documentation and concluded the test does not meet its coverage criteria. Both are appealable, but the strategy differs.

For tests performed without prior authorization, many plans allow a retrospective appeal arguing that the test was medically necessary and that the authorization requirement should be excused or that the plan's process was unclear. For denied authorization requests, the appeal is a substantive medical-necessity challenge.

### Why It Is Appealable

Prior-authorization requirements are procedural gates, not coverage exclusions. When the underlying service is covered and medically necessary, the authorization barrier can often be overcome — either by demonstrating procedural compliance, filing a retrospective exception request, or winning on medical necessity in the appeal. Cigna is required to give you a reason for the denial in writing, and that reason must be based on its published coverage criteria.

### 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 and 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 full-and-fair review and may request the complete administrative record, including Cigna's criteria and the reviewing physician's rationale.
• Expedited review: If delaying the test would seriously jeopardize health or ability to receive timely treatment, request expedited review — decisions are generally required within 72 hours.

### Documentation to Gather

1. Authorization request records — copies of any prior authorization submission, Cigna's denial letter, and the denial reason code. 2. Diagnosis and current clinical status — current pathology report confirming cancer type, histology, and stage. 3. Treating oncologist's medical-necessity letter — a detailed letter explaining the clinical indication, why the test is necessary at this point in the patient's care, and how the result will affect the treatment plan. 4. Applicable guideline reference — citation of the relevant NCCN guideline category or professional society recommendation supporting the test in this clinical scenario. 5. Treatment and testing history — documentation of prior therapies and any prior molecular testing, with explanation of why additional or new testing is required.

### Criteria-Mapping Structure

Download Cigna's current medical coverage policy for the specific test code at cigna.com. Extract each stated coverage criterion. For each criterion, identify the exact chart record, note date, or diagnostic result that satisfies it. Submit this as a structured exhibit alongside the appeal letter. If the original authorization request was denied due to incomplete documentation, the appeal is an opportunity to provide a complete, criterion-by-criterion response that the original submission lacked.