Cimt denied for missing prior authorization by Cigna?

Cigna's specific coverage criteria for cimt are defined in its own published medical/coverage policy and the FDA-approved prescribing label. A successful appeal documents that your medical records satisfy each criterion those sources list — confirmed diagnosis, any required prior treatments (with dates and outcomes), and clinical severity. If the exact criteria weren't included with your denial, request them in writing; your appeal then maps each requirement to the matching fact in your chart.

## Why Cigna Requires Prior Authorization for CIMT — and What to Do If It's Denied

Cigna requires prior authorization for Constraint-Induced Movement Therapy (CIMT) before the service is rendered. A prior-authorization denial means the request was reviewed and declined — most often because the submitted documentation did not satisfy one or more of Cigna's clinical coverage criteria. This is distinct from a "service not yet authorized" situation; a PA denial is a coverage determination that carries full appeal rights.

Prior-authorization denials for CIMT are frequently reversed on appeal because the initial PA request is often submitted without the level of clinical detail Cigna's policy requires — particularly around functional deficit severity, prior therapy history, and rehabilitation potential. A complete, criteria-mapped appeal submission significantly improves the likelihood of approval.

## Federal Appeal Rights

• Internal appeal (ERISA §503 / ACA): You must file within 180 days of the PA denial notice. Cigna must respond within 60 days (30 days for pre-service requests, which PA denials are).
• Urgent/concurrent review: If treatment has already begun or is immediately clinically necessary, request expedited review — Cigna must respond within 72 hours.
• External review (ACA §2719): If the internal appeal is upheld, request independent external review within approximately 4 months. External reviewers apply generally accepted clinical standards, independent of Cigna's internal criteria.

## What to Gather

1. Cigna's CIMT coverage policy: Download the current policy. Map every prior-authorization criterion. Your appeal must address each one explicitly. 2. Diagnosis and onset documentation: Physician records confirming the diagnosis (e.g., stroke, hemiparesis), onset date, and current neurological status. 3. Functional deficit assessment: Standardized clinical measures of upper-limb motor function documented in the medical record — the objective foundation of the medical-necessity argument. 4. Prior conventional therapy records: Dates, duration, treatment goals, and outcomes of prior occupational or physical therapy, establishing the clinical progression that makes CIMT the appropriate next step. 5. Rehabilitation potential documentation: Treating provider's assessment that the patient has sufficient motor and cognitive function to benefit from intensive CIMT — a common PA threshold. 6. Prescriber medical-necessity letter: A detailed letter from the physiatrist, neurologist, or occupational therapist stating the clinical indication, the specific CIMT protocol planned, expected functional outcomes, and the consequence of denial.

## Criteria-Mapping Structure

| Cigna PA Criterion | Supporting Documentation | |---|---| | Confirmed diagnosis and clinical indication | Physician notes, imaging, neurological examination | | Objective upper-limb functional deficit | Standardized assessment results from chart | | Adequate rehabilitation potential | Therapist or physiatrist evaluation | | Prior conventional therapy attempted | Treatment records with dates, goals, and outcomes | | CIMT protocol specified | Prescriber letter describing planned protocol and duration |

Submit the appeal with every supporting document organized to mirror the PA criteria checklist. Include a cover letter that identifies each criterion and the corresponding document page — reviewers process many appeals and a well-organized submission is more likely to result in a complete review.