Why Cigna Denies Shoulder Arthroscopy / Rotator Cuff Repair
Conservative therapy not exhausted (PT, injections)
Partial tear does not meet surgical threshold
Imaging does not correlate with symptoms
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 tear size and location on MRI
Show failure of 3-6 months PT and at least one subacromial injection
Note functional limitations and pain severity
Reference full-thickness tear or significant partial tear (>50%)
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 Rotator Cuff
- AIM Specialty Health Shoulder Surgery Guidelines
Relevant CPT Codes
Specialty: Orthopedics
Want the full strategy?
The P2P Playbook covers payer-specific approaches for Shoulder Arthroscopy / Rotator Cuff Repair 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.
Get The P2P Playbook -- $39Get a personalized P2P script in 60 seconds
Enter your specific case details and our AI generates a structured prep script tailored to Cigna's criteria.