Why Cigna Denies Chemotherapy / Infusion Therapy
Regimen not first-line per NCCN guidelines
Off-label use without compendia support
Continuation after disease progression not justified
Know Cigna / Evernorth's Criteria
Cigna uses their own Coverage Policies and InterQual criteria. Medical directors are generally accessible for P2P review.
Key policies to know:
- Coverage Policies available on cigna.com/coverage-policies
- Uses eviCore for specialty benefits management
- Known for step therapy requirements on specialty drugs
- Collaborative care approach with emphasis on outcomes data
Building Your Medical Necessity Argument
Cite specific NCCN guideline category and recommendation level
Document prior treatment lines and responses
Reference tumor molecular markers guiding treatment selection
If off-label, cite peer-reviewed evidence or compendia listing
P2P Call Tips for Cigna
Reference Cigna Coverage Policy by number
Cigna medical directors tend to be collaborative -- frame it as shared decision-making
Emphasize outcomes data and evidence-based medicine
Be prepared to discuss alternatives and why they were insufficient
Guidelines to Reference
- NCCN Clinical Practice Guidelines by cancer type
- CMS Anticancer Chemotherapy NCD
Relevant CPT Codes
Specialty: Oncology
Want the full strategy?
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