What Cigna requires for coverage
Cigna considers Site of Care: High-tech Radiology medically necessary when the following criteria (from 0550) are met:
- A high-tech imaging service (MRI/MRA/CT/CTA) must meet applicable medical necessity criteria for coverage.
- When coverage criteria are met for the requesting imaging procedure, this coverage policy is used to help determine the medical necessity of the requested site of care.
- Hospital-based imaging is considered medically necessary for an individual with ANY of the following indications:
- Age 18 or under
- Requires obstetrical observation
- Requires perinatology services
- Imaging related to transplantation services at an approved transplantation facility
- Known contrast allergy and use of that contrast agent is planned
- Surgery or procedure is being performed at the hospital and pre-operative or pre-procedure imaging is an integral component of the procedure
- Moderate or deep sedation or general anesthesia is required for the imaging procedure and freestanding facility providing such sedation is not available
- Equipment for the size of the individual is only available at a hospital-based imaging facility
- An open MRI is required because clinical circumstances make a standard closed-bore MRI unsafe, intolerable, or impractical, and no open MRI is available in a freestanding facility
- Known cancer diagnosis and/or chronic disease where imaging needs to be performed at a hospital-based facility for comparison to prior studies, interpretation by a radiology subspecialist, or coordination with treatment services
- Imaging is emergent or urgent and imaging outside the hospital-based imaging department or facility is expected to adversely impact or delay care
How to appeal this denial
Frame your appeal around the specific criterion you satisfy. Quote the 0550 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 0550 — view the published policy.