Cimt denied for failing step therapy 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 Applies Step Therapy to CIMT — and Why You Can Appeal

Cigna's step-therapy ("fail-first") policy for Constraint-Induced Movement Therapy (CIMT) typically requires that a patient first attempt a defined course of conventional occupational therapy or physical therapy before CIMT will be authorized. The denial means Cigna's records do not show sufficient documentation of a prior trial of the required step, or that the clinical rationale for skipping the required step was not established in the original request.

Step-therapy denials for CIMT are frequently reversed on appeal when the patient has already undergone conventional therapy without achieving adequate functional recovery, or when the treating provider documents a clinical reason why the required prior step is not appropriate for this patient's specific presentation. CIMT is not merely "more intensive" occupational therapy — it is a distinct protocol with a different mechanism, and major rehabilitation guidelines recognize it as appropriate when conventional therapy has been insufficient.

## Federal Appeal Rights

• Internal appeal (ERISA §503 / ACA): File within 180 days of denial. Cigna must respond within 60 days (30 days for pre-service).
• External review (ACA §2719): Available after internal exhaustion, within approximately 4 months of the final denial. External reviewers apply generally accepted clinical standards and can find that a step-therapy requirement is clinically inappropriate for the patient's specific situation.
• Expedited review: Request within 72 hours if delay poses clinical risk — particularly if the patient is within a window of neuroplastic recovery where delayed treatment reduces expected outcomes.
• State step-therapy override laws: Depending on the state and plan type, applicable step-therapy override laws may require Cigna to grant an exception when clinical evidence supports direct access to CIMT.

## What to Gather

1. Prior conventional therapy records: If the required step was already taken, provide complete records: dates, treatment setting, goals, duration, standardized outcome measures, and reason for discontinuation or conclusion that further conventional therapy is insufficient. 2. Inadequacy of prior step: A letter from the treating therapist or physiatrist explaining why conventional occupational therapy did not achieve adequate functional recovery and why CIMT is the appropriate next intervention. 3. Medical inappropriateness of the required step (if applicable): If the required step was not taken because it was clinically inappropriate, document the specific clinical rationale — e.g., the patient's motor function level or clinical profile is one for which CIMT is the guideline-recommended primary intervention. 4. Guideline support: Reference to applicable AHA/ASA or rehabilitation guideline recommendations that support CIMT as the appropriate intervention at this point in the patient's recovery trajectory. 5. Cigna's step-therapy policy and exception criteria: Identify every required step and every stated exception. Address each one in the appeal.

## Criteria-Mapping Structure

| Cigna Step-Therapy Requirement | Your Documentation | |---|---| | Required prior therapy (e.g., OT) tried | Records with dates, goals, outcomes, and assessments | | Prior therapy resulted in inadequate recovery | Therapist/prescriber letter documenting residual deficit | | OR: exception — prior step clinically inappropriate | Clinical rationale letter with guideline support | | CIMT is guideline-supported next step | AHA/ASA or equivalent guideline citation | | Current functional deficit justifies CIMT | Standardized assessment results from current chart |

The most effective step-therapy appeals for CIMT combine objective functional deficit documentation with a clear clinical narrative explaining why the recovery trajectory calls for CIMT specifically — not just additional conventional therapy.