By Counterforce Health Team in Darzalex / Darzalex Faspro (daratumumab) —

How to Get Darzalex Covered by Cigna in New York: Appeal Templates, Timelines & Prior Authorization Guide

Answer Box: Getting Darzalex Covered by Cigna in New York

If Cigna denies Darzalex (daratumumab) coverage, you can appeal within 180 days. Most denials stem from insufficient prior therapy documentation or missing age verification (≥18 required). Quick action steps: 1) Call Cigna at 1-800-882-4462 for clarification, 2) Gather complete treatment history showing prior regimen failures, 3) Submit written appeal with medical records to address in your denial letter. New York residents can request external review through the Department of Financial Services if internal appeals fail. Community Health Advocates offers free assistance at 888-614-5400.

Table of Contents

Coverage Requirements at a Glance

Requirement What It Means Where to Find It Source
Prior Authorization Required for all Darzalex formulations Cigna member portal or provider Cigna PA Policy
Age Requirement Patient must be ≥18 years old Birth date verification in medical records Cigna PA Policy
Prior Therapy Must have tried at least one other regimen Treatment history documentation Cigna PA Policy
Prescriber Must be oncologist or hematologist NPI and specialty certification Cigna PA Policy
Appeal Deadline 180 calendar days from denial Denial letter date stamp Cigna Appeals Process
External Review 4 months after final internal denial New York DFS portal NY DFS External Appeals

Reading Your Denial Letter

Your Cigna denial letter contains critical information for your appeal. Look for these key elements:

Denial Reason Codes: Cigna uses specific codes to indicate why coverage was denied. Common codes for Darzalex include:

  • Medical necessity not established
  • Prior authorization requirements not met
  • Age criteria not satisfied
  • Insufficient prior therapy documentation

Appeal Instructions: The letter must include specific instructions on how to appeal, including the address where to send your appeal and the 180-day deadline.

Required Documentation: Note what additional information Cigna requests, such as treatment history, pathology reports, or physician attestations.

Tip: Keep the original denial letter—you'll need to reference the specific denial code and case number in your appeal.

Common Denial Reasons & Quick Fixes

Denial Reason How to Fix It Documents Needed
Insufficient prior therapy Provide detailed treatment timeline Complete regimen history with dates, outcomes
Age not verified Submit birth certificate or ID Official age verification document
Wrong prescriber specialty Get referral or consultation note Oncologist/hematologist NPI and credentials
Missing diagnosis confirmation Include pathology reports Multiple myeloma biopsy results, ICD-10 codes
Incorrect dosing/schedule Align with FDA label or NCCN FDA prescribing information

Step-by-Step: Fastest Path to Approval

1. Call Cigna Customer Service (Day 1)

Who: Patient or authorized representative
Number: 1-800-882-4462
Goal: Clarify denial reason and confirm requirements
Timeline: 15-30 minutes

2. Gather Required Documentation (Days 1-3)

Who: Patient with clinic support
Documents: Treatment history, pathology reports, physician notes
Timeline: 2-3 business days

3. Contact Your Oncologist (Days 2-5)

Who: Patient or care coordinator
Request: Medical necessity letter addressing specific denial reasons
Timeline: 3-5 business days

4. Submit Written Appeal (Days 5-10)

Who: Patient or clinic
Method: Mail to address in denial letter
Include: Appeal form, medical records, physician letter
Timeline: Submit within 180 days of denial

5. Track Your Appeal (Days 10-75)

Who: Patient
Method: Cigna member portal or phone
Timeline: Cigna has 60-75 business days to respond

6. Request Peer-to-Peer if Needed (As appropriate)

Who: Prescribing physician
When: If initial appeal is denied
Process: Direct physician-to-physician discussion

7. File External Review if Necessary (After internal appeals)

Who: Patient
Where: New York DFS portal
Deadline: 4 months after final internal denial

Filing Your First-Level Appeal

Your written appeal should include:

Patient Information:

  • Full name and Cigna member ID
  • Date of birth (to satisfy age requirement)
  • Contact information

Clinical Documentation:

  • Multiple myeloma diagnosis with ICD-10 codes (C90.00-C90.02)
  • Complete prior treatment history showing regimen failures
  • Current disease status and treatment rationale
  • Prescribing physician's NPI and specialty certification

Medical Necessity Letter: Your oncologist should address:

  • Why Darzalex is medically necessary for your specific case
  • How you meet Cigna's published criteria
  • Reference to NCCN guidelines supporting daratumumab use
  • Documentation of prior therapy inadequacy or failure

Supporting Evidence:

  • Pathology reports confirming multiple myeloma
  • Laboratory results showing disease progression
  • Documentation of prior regimen intolerance or contraindications

Submit to the address listed in your denial letter, typically: Cigna Healthcare Inc. National Appeals Unit (NAO)
PO Box 188062
Chattanooga, TN 37422
(Verify address in your specific denial letter)

Peer-to-Peer Review Process

If your written appeal is denied, request a peer-to-peer review where your oncologist can speak directly with Cigna's medical director.

Scheduling: Contact Cigna provider services to request the call
Preparation: Your physician should review:

  • Cigna's specific denial reasons
  • Your complete treatment history
  • Current NCCN guidelines for multiple myeloma
  • Clinical evidence supporting Darzalex use

Key Talking Points:

  • Patient meets age requirement (≥18)
  • Prior therapy history demonstrates at least one regimen trial
  • Current regimen aligns with NCCN Category 1 recommendations
  • Medical necessity based on disease characteristics

New York External Review Rights

New York residents have strong appeal rights through the Department of Financial Services external review process.

When to Use: After exhausting internal appeals with Cigna
Deadline: 4 months from final internal denial
Cost: $25 fee (waived for Medicaid or financial hardship)
Process: Independent medical expert reviews your case
Timeline: Standard review within 45 days; expedited within 72 hours for urgent cases

How to Apply:

  1. Complete the external appeal form
  2. Include all medical records and Cigna's denial letters
  3. Submit supporting documentation from your physician
  4. Reference similar cases in the DFS appeals database

Free Help Available: Contact Community Health Advocates at 888-614-5400 for assistance with external appeals.

Appeal Letter Templates

Patient Appeal Letter Template

[Date]

Cigna Healthcare Inc. National Appeals Unit
[Address from your denial letter]

RE: Appeal for [Patient Name]
Member ID: [Your ID number]
Denial Reference: [Number from denial letter]

Dear Appeals Review Team,

I am writing to formally appeal the denial of coverage for Darzalex (daratumumab) dated [denial date]. I believe this denial is incorrect based on the medical evidence and Cigna's own coverage criteria.

Medical Necessity:
• I am [age] years old, meeting the ≥18 age requirement
• I have a confirmed diagnosis of multiple myeloma (ICD-10: [specific code])
• I have previously tried [list specific prior regimens with dates]
• My oncologist, Dr. [Name] (NPI: [number]), has determined Darzalex is medically necessary

The requested treatment aligns with NCCN guidelines and Cigna Policy 1403. Enclosed documentation demonstrates I meet all coverage criteria.

Respectfully requesting reconsideration,
[Your signature]
[Your name]

Physician Medical Necessity Letter Template

[Letterhead]

To Whom It May Concern:

I am writing to support coverage for Darzalex (daratumumab) for my patient [Name], DOB [date], Cigna member ID [number].

Clinical Summary:
• Confirmed multiple myeloma diagnosis on [date] with pathology showing [details]
• Prior treatments: [specific regimens, dates, outcomes/failures]
• Current disease status: [progression, response, etc.]

Medical Necessity Rationale:
This patient meets all criteria in Cigna Policy 1403:
1. Age ≥18 years: Patient is [age] years old
2. Prior therapy: Patient previously received [specific regimen] with [outcome]
3. Appropriate prescriber: I am a board-certified [oncologist/hematologist]

The requested daratumumab regimen is supported by NCCN Category 1 evidence and is standard of care for this clinical scenario.

Sincerely,
[Physician name and credentials]
NPI: [number]
From our advocates: "We've seen appeals succeed when physicians specifically reference Cigna's policy number and criteria in their letters. Including exact dates and outcomes of prior therapies—not just drug names—makes a significant difference in medical review."

When to Escalate

Consider escalating your case if:

  • Cigna doesn't respond within required timeframes (60-75 business days)
  • You receive conflicting information from different representatives
  • The denial appears to contradict Cigna's published policy
  • Your physician believes the denial is inappropriate

Escalation Options:

New York Department of Financial Services
Consumer Assistance: 1-800-342-3736
File a complaint online

Community Health Advocates
Free insurance appeal assistance
Phone: 888-614-5400
Website: communityhealthadvocates.org

Cigna Executive Escalation
If internal processes fail, consider written complaints to Cigna's executive team with copies to state regulators.

Cost Assistance Programs

While working on your appeal, explore financial assistance:

Johnson & Johnson Patient Assistance
Janssen CarePath offers copay support and patient assistance programs for eligible patients.

Foundation Support
Organizations like the Leukemia & Lymphoma Society and Patient Advocate Foundation provide grants for cancer treatment costs.

New York State Programs
The Essential Plan and Medicaid expansion may provide coverage options for eligible residents.

Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals. The platform helps patients, clinicians, and specialty pharmacies get prescription drugs approved by identifying denial reasons and drafting point-by-point rebuttals aligned to each plan's specific rules and requirements.

FAQ

How long does Cigna prior authorization take for Darzalex in New York?
Standard PA decisions are made within 72 hours for non-urgent requests and 24 hours for urgent cases. Appeals take 60-75 business days.

What if Darzalex is non-formulary on my Cigna plan?
Request a formulary exception with medical necessity documentation. Your physician must demonstrate why covered alternatives are inappropriate.

Can I request an expedited appeal?
Yes, if your health would be seriously jeopardized by delay. Expedited appeals are decided within 72 hours.

Does New York's step therapy reform affect Darzalex coverage?
Starting January 2026, New York limits step therapy requirements. Insurers cannot require more than two drug trials or continue step therapy beyond 30 days if medically inappropriate.

What happens if my external appeal is denied?
External review decisions are binding on insurers. If denied, consider legal consultation or explore alternative treatments and assistance programs.

Can Community Health Advocates help with Cigna appeals?
Yes, CHA provides free assistance to New York residents appealing insurance denials, including specialty drug coverage disputes.

How do I prove prior therapy failure to Cigna?
Provide detailed treatment records showing specific regimens, dates of treatment, clinical response (or lack thereof), and reasons for discontinuation.

What if I move to New York from another state during treatment?
Your appeal rights transfer with you. New York's external review process applies to state-regulated plans regardless of where treatment began.

Disclaimer: This information is for educational purposes and is not medical or legal advice. Insurance coverage decisions depend on individual policy terms and clinical circumstances. For personalized guidance, consult your healthcare provider and insurance representative. Counterforce Health provides specialized support for navigating insurance appeals and prior authorization requirements.

Sources & Further Reading

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