Why Cigna Denies Sleep Study (Polysomnography)
Home sleep test not attempted first
Epworth Sleepiness Scale not documented
Symptoms do not meet criteria for in-lab study
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 ESS score and clinical symptoms
Note comorbidities requiring in-lab study (CHF, COPD, neuromuscular disease)
If home test failed or was inconclusive, document results
Reference BMI and neck circumference
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
- AASM Clinical Practice Guidelines for Sleep Apnea
- CMS NCD for Sleep Testing
Relevant CPT Codes
Specialty: Pulmonology / Sleep Medicine
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