Why Cigna Denies Total Hip Replacement
Conservative management not exhausted
BMI exceeds payer threshold (often >40)
Imaging does not show severe joint disease
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 Kellgren-Lawrence grade on imaging
Show failure of NSAIDs, PT, injections, activity modification
Note functional limitations using validated outcome measures
Address BMI and optimization 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
- AAOS Clinical Practice Guidelines for Hip OA
- MCG Criteria for Total Joint Replacement
Relevant CPT Codes
Specialty: Orthopedics
Want the full strategy?
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