Why Cigna Denies PET/CT Scan
Staging not appropriate for tumor type
Follow-up scan too soon after treatment
Diagnosis does not meet NCD criteria
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
Cigna's Specific Approach to PET/CT Scan
Applicable Policy
Cigna Coverage Policy IP0098 (PET/CT Imaging)
How Cigna Typically Denies This
Cigna focuses on whether conventional imaging (CT, MRI) was performed first and whether the PET will provide information not available from other modalities. They may deny if CT staging was considered sufficient.
Your Strategy for This Payer
Explain the specific clinical question that PET answers that CT cannot: metabolic activity vs. anatomic abnormality, distinguishing scar from recurrence, identifying occult disease not visible on CT.
Key Phrase to Use on the Call
"CT imaging is insufficient for [specific reason -- e.g., distinguishing post-treatment fibrosis from residual disease], and PET/CT is the only modality that can provide the metabolic information needed for treatment planning."
Building Your Medical Necessity Argument
Reference the specific NCD indication being met
Document how PET results will change management
Note prior imaging results that are insufficient
Cite NCCN guideline recommendation for PET at this stage
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 National Coverage Determination for FDG PET
- NCCN Guidelines by cancer type
Relevant CPT Codes
Specialty: Oncology / Pulmonology
Want the full strategy?
The P2P Playbook covers payer-specific approaches for PET/CT Scan denied by Cigna -- plus 15 denial objections with word-for-word responses, what reviewers are actually thinking, and the 60-second prep framework. Written by a medical director who reviewed cases for major payers.
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