How to appeal a Cigna inpatient rehab — irf / snf / ltac admission and length-of-stay denial

The framework that applies to your appeal

Federal law gives you the right to a full and fair internal appeal, then an external review by an independent third party.

Cigna-specific note: Sold its Medicaid Advantage book to HCSC in 2023. Express Scripts (PBM) is Cigna-owned. Frequent class-action litigation around mental health parity.

What Cigna's policy requires for inpatient rehab — irf / snf / ltac admission and length-of-stay

Cited policy: Cigna coverage policy Inpatient Rehabilitation Facility (IRF)

All five 42 CFR §412.622 criteria met: multidisciplinary therapy intensity (3 hr/day 5 days/week OR 15 hr in 7); physiatrist supervision >=3 visits/week; PAS within 48 hr; expectation of measurable functional improvement OR Jimmo maintenance; interdisciplinary team approach. Specifies that diagnosis-based denials must reference §412.29 qualifying-condition list.

How Cigna denies inpatient rehab — irf / snf / ltac admission and length-of-stay — and how to counter it

Where Cigna pushes back: 1) 'Patient does not meet IRF criteria'; 2) 'SNF appropriate'; 3) 'Therapy hours documentation insufficient'; 4) 'PAS not timely'; 5) Continued-stay denials at day 7-10 alleging 'reached plateau'.

Counter-arguments that hold up: Quote Cigna's own CCP 0500 criteria point-by-point; demonstrate each met. Submit physiatrist PAS with clinical justification. Section GG / FIM scores; therapy tolerance documented at acute hospital (e.g., 3.2 hr/day combined PT/OT/SLP). For continued-stay: submit interim functional gain (FIM delta, Section GG delta) OR Jimmo maintenance argument. Note IRF requires multidisciplinary team + physiatrist supervision + rehab nursing — none available at SNF level.

What Cigna typically denies for inpatient rehab — irf / snf / ltac admission and length-of-stay

Across Cigna's commercial and Medicare books, denials cluster around a small number of patterns. For inpatient rehab — irf / snf / ltac admission and length-of-stay, expect:

• Mental health parity violations
• Step therapy
• Specialty drug prior auth
• OON balance billing disputes

Treatments most often denied in this category

These are the inpatient rehab — irf / snf / ltac admission and length-of-stay treatments most often flagged for prior auth, step therapy, or medical necessity review:

• IRF admission
• IRF length-of-stay
• SNF admission
• SNF length-of-stay
• LTAC admission
• LTAC length-of-stay

How to submit the appeal to Cigna

1. Read the denial letter — note the exact denial reason code and the appeal deadline (180 days from the date on the letter).
2. Gather supporting documentation: physician letter of medical necessity, relevant clinical notes, peer-reviewed citations supporting the treatment for your indication, and the policy or coverage document Cigna cited in the denial.
3. File the appeal through Cigna's portal (members: https://my.cigna.com ; providers: https://cignaforhcp.cigna.com). Standard decision returns within 30 days; expedited urgent appeals return within 72 hours.
4. If denied again, request external review by an independent reviewer within 4 months of the final internal denial. In CT, the state insurance department coordinates external review for fully-insured plans; ERISA self-funded plans use a federal external review through DOL/EBSA.

Clinician or prior-auth team handling this on the practice side? See Cigna's prior-authorization criteria by drug: Cigna PA criteria on ApprovalHelp.