Why Cigna Denies CPAP / BiPAP Equipment
Sleep study does not meet AHI threshold
Prior compliance data not submitted
Home sleep test required before in-lab PSG
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
Document AHI >= 15 or AHI 5-14 with symptoms/comorbidities
Include sleep study interpretation by qualified physician
For replacement, show compliance data (>4 hours/night, >70% of nights)
Note clinical symptoms (excessive daytime sleepiness, hypertension, CHF)
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
- CMS NCD for CPAP Therapy
- AASM Clinical Practice Guidelines
Relevant CPT Codes
Specialty: Pulmonology / Sleep Medicine
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