Cigna denying pre-approvals (Help)

[unchosen]

Apologies if this is not the right place, but I’m new to this and need help understanding my options here.

Went and got an X-ray for some constant knee pain and my orthopedist referred me for an MRI on the area due to noticing significant subluxation of my patella. Cigna approved the X-ray, but denied the MRI for lack of medical necessity. Reasoning was that Evicore Healthcare’s guidelines said I needed a 6 week PT or NSAID plan before they would approve it.
I could normally understand this as if it’s in their guidelines then it’s how they operate, fine. But when I looked at their guidelines, I saw that under dislocation/subluxation, that 6 week plan was deemed unnecessary and that an MRI was the next recommended step.
I appealed this decision and received the same reasoning that I had not gone through the 6 week treatment plan so it was not medically necessary.
I went ahead and paid for the MRI out of pocket just to move my treatment along as my pain was worsening, and my doctor recommended surgery after the MRI confirmed that my cartilage under the patella was beginning to wear down prematurely.
Cigna has now denied the surgery after it being submitted only 3 days prior for reasons of no imaging showing weakened tissues or cartilage tears, and also no X-ray showing the kneecap is out of place or a defect in the knee.
I’m at my wits end when dealing with them as every time I call I get passed from person to person who claim they are not authorized to deal with what I’m asking about, and I am so new to insurance in general that I don’t understand my options.
Sorry for the long post, but I’m sick to my stomach with worry because I can’t afford the surgery on my own and it has become increasingly painful to walk. Is my only option continuing to argue with call center employees who just run me around?

 

[foreverthankful]

@unchosen Sounds to me like the denial is due to Cigna not receiving copies of your X-Ray and MRI.

I would request that your doctor resubmit with the imaging files so Cigna can review.

If you get your insurance through your employer, I also recommend asking your HR team to ask your broker for assistance or to direct your issue to the dedicated account rep at Cigna. The dedicated service rep can tell you exactly why things were denied and what can be submitted to get an approval.

I've had this EXACT situation with one of my clients and when I, as the broker, connected with my Cigna rep, the denial for the MRI was because the MRI without contrast was a better fit and less expensive and the MRI WITH contrast that the provider asked for was what was getting denied- but the Cigna rep that your Broker/HR team has contact with will be able to give you a better idea of what's going on.

 

[gdtcn2022]

@unchosen Evicore is a denial machine. But the previous poster is correct contact Cigna. Appeal - the appeal will eventually be send back to your insurance company. While you are waiting, you can look up all the court cases against Evicore for denial of imaging. BTW I Cigna owns Evicore.

 

[unchosen]

@gdtcn2022 So I actually did call Cigna to ask about if my imaging files were used in the decision since looking back it was only 1 business day to make the decision. They told me there was a peer to peer scheduled with my doctor to appeal the decision already scheduled for a week from now. Do these normally work? I can’t seem to find info anywhere on the effectiveness of peer to peer appeals on overturning a denial.

 

[gdtcn2022]

@unchosen I have not had much success, but I am a physical therapist. I learned if the peer to peer fails the next step is your doctor has to appeal back to your insurance company. I am not sure if the patient can be involved, but I have always got approval when I go back to the actual insurance company. Evicore will give a short time limit for which your MD had to appeal. It's a hard date. Good luck!

 

[passingthrough1]

@unchosen Doctors have success with peer to peers. Sometimes they are missing some basic information in your clinical notes like the reasons why physical therapy cannot be tried. I worked in precert for an ortho office and for a hospital too. That was the main reason for denials. Lack of physical therapy or at least a reason why it couldn’t be done. The doctors always have the option for a reconsideration, peer to peer and appeal for both radiology and surgeries for commercial insurance plans like Cigna. Ins can get a bad rap but a lot of times it’s poor or missing documentation from the physicians office