Cigna

Appeal Deadlines

Commercial: 180 days from denial date

Medicare: 60 days for Medicare Advantage

Key Facts

• +Cigna uses EviCore, a third-party prior authorization management company, for many specialty services including radiology, oncology, and musculoskeletal procedures.
• +Cigna was the subject of a lawsuit alleging its AI claim review system spent 1.2 seconds per claim, resulting in over 300,000 denials in two months.
• +Cigna was rated by 55% of physicians as having high or extremely high prior authorization burden.
• +Cigna announced reductions in prior authorization requirements in 2023, but only 16% of physicians reported seeing a reduction in practice.

What to Watch

• +If your prior authorization was denied by EviCore, your appeal goes to EviCore first, not directly to Cigna. Know which pathway applies to your service.
• +Cigna's medical policies are published on their website and define what they consider medically necessary. Reference these in your appeal.

Appeal Tips

1. Determine whether your service is managed by EviCore or directly by Cigna. The appeal process differs.
2. For EviCore-managed services, request a clinical peer-to-peer review. EviCore overturns a significant percentage of denials at this stage.
3. Include detailed clinical documentation that directly addresses the specific criteria in Cigna's medical policy for your service.

Resources

• Cigna Medical Coverage Policies
• EviCore Prior Authorization