Why Cigna Denies Inpatient Rehabilitation Facility (IRF)
Patient does not require 3 hours/day therapy intensity
Skilled nursing facility is appropriate alternative
Medical complexity does not warrant IRF level
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 ability to participate in 3+ hours/day of therapy
List qualifying diagnoses under the 60% rule
Note medical complexity requiring physician supervision
Explain why SNF level is insufficient for this patient
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 IRF Coverage Requirements (60% Rule)
- InterQual Criteria for Rehabilitation Facility Admission
Relevant CPT Codes
Specialty: Physical Medicine & Rehabilitation
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