ECT denied as non-formulary by Cigna?

Cigna's specific coverage criteria for ect 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 May Issue a Non-Formulary Denial for Electroconvulsive Therapy (ECT)

ECT is a procedure, not a drug, so a "non-formulary" denial in this context most commonly means that ECT is not included in Cigna's covered-benefits list for your specific plan, that the specific facility or provider performing ECT is out of network, or that the procedure code submitted does not match Cigna's coverage policy for this service. Occasionally, the non-formulary designation arises when a plan covers ECT only under narrow conditions and treats any request outside those conditions as a non-covered benefit.

## Why This Denial Is Appealable

If your plan includes mental health benefits, the Mental Health Parity and Addiction Equity Act (MHPAEA) requires that the scope of covered mental health services not be more restrictive than the scope of analogous medical or surgical services. Excluding ECT entirely — or applying a non-formulary restriction that does not exist for comparable medical procedures — may constitute a parity violation. Additionally, if the denial is based on an out-of-network provider, you may have a right to an exception if no in-network provider can deliver ECT in your area. Under ERISA §503 and ACA §2719, you have the right to a full-and-fair review of any adverse benefit determination.

## Federal Appeal Framework

• Internal appeal: File within the deadline on your denial notice. Request your plan's complete Summary of Benefits and Coverage, the mental health coverage section, and any utilization-management guidelines applied to ECT.
• External review: Available after final internal denial. An IRO can evaluate both the coverage determination and any potential parity violation. The standard external-review window is approximately four months from the final adverse determination; expedited review is available when there is clinical urgency.

## Concrete Appeal Steps

1. Obtain your Summary Plan Description (SPD) and confirm whether mental health services are covered — if so, ECT should be covered under MHPAEA unless the plan can justify a parity-compliant exclusion. 2. If the denial is provider-network based, ask Cigna to identify in-network providers who can perform ECT in your geographic area; if none exist, request an out-of-network exception (network-adequacy exception). 3. If the denial is based on procedure-code mismatch, have your provider review the submitted codes and resubmit with correct coding if appropriate. 4. File a MHPAEA parity challenge: ask Cigna to identify the comparable medical/surgical procedure for which it does not apply the same non-formulary restriction. 5. Submit the internal appeal with your parity challenge, the non-formulary exception request, and clinical documentation supporting medical necessity.

## Documentation to Gather

• Diagnosis confirmation: Psychiatric chart notes establishing the diagnosis and medical indication for ECT.
• Prior-treatment history: Records of prior treatments, showing the clinical pathway that led to the ECT recommendation.
• Clinical severity: Psychiatrist documentation of current severity and the reason ECT is the appropriate next intervention.
• Prescriber medical-necessity letter: A letter from the treating psychiatrist supporting both the medical necessity and, if applicable, the network-exception request.
• Plan documents: Your SPD and any EOB (Explanation of Benefits) associated with the denial.
• Network-adequacy evidence: If an out-of-network exception is needed, documentation that no in-network provider capable of delivering ECT exists within a reasonable distance.

## Criteria-Mapping Structure

Identify the precise basis for the non-formulary denial — is it a coverage exclusion, a network issue, or a coding issue? For each basis, provide the corresponding plan document language, the clinical documentation, and the legal argument (MHPAEA or network adequacy) that requires coverage. Separating these into distinct sections makes the appeal reviewable and harder to deny on multiple grounds simultaneously.