How to appeal a Cigna pediatric therapy 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 pediatric therapy

Cited policy: Cigna coverage policy - Speech Therapy / 0265 OT / 0266 PT / 0499 ABA

Diagnosis-based; measurable goals; individualized plan; parent involvement.

How Cigna denies pediatric therapy — and how to counter it

Where Cigna pushes back: 1) 'Custodial' or 'habilitative not rehabilitative'; 2) Hour/visit caps; 3) Feeding therapy 'not medical' when ARFID/sensory feeding aversion.

Counter-arguments that hold up: ACA §1302(b)(1)(G) — habilitative services are required EHB; 'not rehabilitative' is NOT a lawful basis for denial in ACA-compliant plans. For feeding: ICD-10 F50.82 (ARFID) or R63.3 + SLP/OT eval documenting dysphagia (R13.x) or oral-motor dysfunction; cite ASHA Pediatric Dysphagia Practice Portal.

What Cigna typically denies for pediatric therapy

Across Cigna's commercial and Medicare books, denials cluster around a small number of patterns. For pediatric therapy, 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 pediatric therapy treatments most often flagged for prior auth, step therapy, or medical necessity review:

• ABA therapy
• Speech therapy
• OT
• PT
• Feeding therapy
• Vision therapy

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.