Why Cigna Denies Genetic / Genomic Testing
Test not considered medically necessary for this diagnosis
Does not meet hereditary cancer testing criteria
Results will not change treatment plan
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 how test results will directly change management
Meet NCCN testing criteria (family history, age, tumor type)
Reference specific actionable mutations being tested
Note FDA-approved companion diagnostics if applicable
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 Genetic/Familial High-Risk Assessment Guidelines
- CMS NCD for Next Generation Sequencing
Relevant CPT Codes
Specialty: Oncology / Medical Genetics
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