How to appeal a Cigna stroke & neuro rehab 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 stroke & neuro rehab

Cited policy: Cigna coverage policy — Constraint-Induced Movement Therapy

EXCITE inclusion criteria: >=10° active wrist extension, >=10° active finger extension, no severe cognitive impairment, sufficient stamina, willingness for daily mitt use.

How Cigna denies stroke & neuro rehab — and how to counter it

Where Cigna pushes back: 1) Experimental; 2) Patient does not meet EXCITE criteria; 3) Insufficient evidence.

Counter-arguments that hold up: EXCITE Wolf JAMA 2006;296:2095 — Level 1 RCT demonstrating CIMT superiority. AHA/ASA 2016 Class IIa LOE A for CIMT in eligible patients (>=10° wrist extension, >=10° finger extension). VECTORS Stroke 2009 dose-timing. ACRM endorsement. Submit Fugl-Meyer + active ROM measurements + cognitive screen (MoCA) + caregiver support documentation.

What Cigna typically denies for stroke & neuro rehab

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

• Acute thrombectomy / tPA
• IRF admission
• LTACH
• SNF sub-acute
• Outpatient PT/OT/SLP
• CIMT

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.