Why Cigna Denies Colonoscopy
Screening interval not met
Prior authorization not obtained
Age does not meet screening criteria
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
Distinguish diagnostic from screening indication
Document symptoms warranting diagnostic colonoscopy
Reference family history or personal risk factors
Note positive screening test (FIT, Cologuard) requiring follow-up
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
- USPSTF Colorectal Cancer Screening Recommendations
- AGA Guidelines for Colonoscopy Surveillance
- NCCN High-Risk Screening Guidelines
Relevant CPT Codes
Specialty: Gastroenterology
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