How to Appeal a Cigna Emergency Room Services Denial

What Cigna requires for coverage

Cigna considers Emergency Room Services medically necessary when the following criteria (from A005) are met:

• Emergency room services are provided for treatment of an emergency medical condition.
• Emergency medical conditions are defined as circumstances where the individual perceives their symptoms to be so severe that not seeking immediate medical attention could result in serious harm.
• Covered emergency room services provided by a non-participating (out of network) provider or facility are eligible for coverage at the in-network cost-share benefit plan level.
• Covered emergency room services DO NOT require prior authorization and/or referral by a healthcare provider.
• Covered services include EACH of the following: A physical and/or mental examination and related healthcare services to evaluate an emergency medical condition; Treatment to stabilize the individual.

How to appeal this denial

Frame your appeal around the specific criterion you satisfy. Quote the A005 language above, then show — with your physician's records and clinical evidence — exactly how your situation meets it. Demand that Cigna either approve the claim or identify the precise criterion they believe you fail. CareCost Appeals assembles this automatically: it cites the policy, pulls verified clinical evidence, and applies your state and federal appeal rights.

Source: Cigna medical policy A005 — view the published policy.