Why Cigna Denies Hysterectomy
Conservative management not exhausted (hormonal therapy, ablation)
Uterine size does not meet threshold
Alternative less invasive procedures not tried
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 failure of hormonal management
Note uterine size and symptom severity
Explain why less invasive alternatives are not appropriate
Reference impact on quality of life and functional status
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
- ACOG Practice Bulletin on Hysterectomy
- AAGL Practice Guidelines for Hysterectomy
Relevant CPT Codes
Specialty: Gynecology
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