How to appeal a Cigna neuropsychological & psychological testing — adhd, tbi, dementia, asd, presurgical eval 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 neuropsychological & psychological testing — adhd, tbi, dementia, asd, presurgical eval

Cited policy: Cigna coverage policy Neuropsychological Testing

Documented cognitive decline (history + bedside screen abnormal OR pre-morbid baseline indicates decline); brain imaging + lab workup completed (B12, TSH, RPR, HIV); differential diagnosis required (MCI vs AD vs FTD vs LBD vs vascular vs depression).

How Cigna denies neuropsychological & psychological testing — adhd, tbi, dementia, asd, presurgical eval — and how to counter it

Where Cigna pushes back: 1) MoCA/MMSE not abnormal enough; 2) Imaging/labs not yet completed; 3) 'Not medically necessary' if dementia already presumptively dx; 4) Hours excessive.

Counter-arguments that hold up: MoCA cutoff 26/30 is screening — domain-specific characterization requires comprehensive battery (NAN 2019). Mahncke Alz Dem 2018 + Manly Neurology 2008 demonstrate neuropsych identifies treatable causes + predicts MCI→AD conversion. AAN MCI Practice Guideline (Petersen Neurology 2018) supports neuropsych in differential. Document imaging + lab completion. Submit screening showing impairment OR pre-morbid baseline mismatch (e.g., professor with MoCA 26 = below expected). Differential dx alters treatment (cholinesterase inhibitor vs memantine vs no medication; driving safety; family planning).

What Cigna typically denies for neuropsychological & psychological testing — adhd, tbi, dementia, asd, presurgical eval

Across Cigna's commercial and Medicare books, denials cluster around a small number of patterns. For neuropsychological & psychological testing — adhd, tbi, dementia, asd, presurgical eval, 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 neuropsychological & psychological testing — adhd, tbi, dementia, asd, presurgical eval treatments most often flagged for prior auth, step therapy, or medical necessity review:

• Comprehensive neuropsych battery
• ADHD neuropsych eval
• Post-concussion / mTBI eval
• Moderate-severe TBI eval
• Dementia workup
• ASD diagnostic eval

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.