ECT denied for missing prior authorization 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 Requires Prior Authorization for Electroconvulsive Therapy (ECT)

Cigna requires prior authorization for ECT because it is classified as a high-cost, specialized procedure in its utilization-management program. A prior-authorization denial means the procedure was performed or requested without Cigna's advance clinical review. This type of denial does not mean ECT is excluded from your benefits — it means the plan's process was not followed before the service was delivered or scheduled.

## Why This Denial Is Appealable

Retroactive prior-authorization denials — issued after ECT has already been administered — are among the most defensible appeals. Under ERISA §503 and ACA §2719, the plan must evaluate the clinical merits of the request, not just the procedural failure. Courts and IROs consistently hold that a purely procedural denial, without any clinical basis for finding the service unnecessary, cannot stand. If the ECT was medically necessary, the procedural failure alone is not a sufficient basis to deny coverage. Additionally, if your clinical situation was urgent — a genuine psychiatric emergency — the urgency itself may excuse the failure to obtain advance authorization.

The Mental Health Parity and Addiction Equity Act also applies: if Cigna does not require prior authorization for comparable medical or surgical procedures of similar cost and complexity, requiring it for ECT may be a parity violation.

## Federal Appeal Framework

• Internal appeal: File within the deadline on your denial notice. Request the PA criteria Cigna would have applied had a timely request been submitted.
• External review: Available after final internal denial. The standard external-review window is approximately four months from the final adverse determination. Expedited review is available — and particularly appropriate for ECT — when ongoing treatment is clinically urgent.

## Concrete Appeal Steps

1. Determine why PA was not obtained in advance — prescriber oversight, plan communication failure, or clinical urgency — and document that reason clearly. 2. Obtain Cigna's ECT prior-authorization criteria and have your psychiatrist confirm in writing that your case would have met every criterion had a timely request been submitted. 3. If the ECT was clinically urgent, have your psychiatrist document the urgency and explain why waiting for PA would have posed a risk to health or safety. 4. Submit a retroactive PA request alongside the appeal if Cigna's process permits — many plans allow concurrent filings. 5. Raise MHPAEA: ask Cigna to identify comparable medical or surgical procedures of similar complexity for which it does not require PA.

## Documentation to Gather

• Diagnosis confirmation: Current psychiatric evaluation establishing the diagnosis, severity, and clinical rationale for ECT.
• Prior-treatment history: A comprehensive, dated record of all prior treatments, their duration, and their outcomes — demonstrating that ECT was the clinically appropriate next step.
• Clinical severity: Psychiatrist documentation of the patient's status at the time ECT was recommended, including any urgent or emergent factors.
• Prescriber medical-necessity letter: A letter from the treating psychiatrist confirming medical necessity, addressing each PA criterion, and explaining (if applicable) the clinical urgency that made advance PA impractical.
• PA process documentation: Any records of PA attempts, prescriber communications with Cigna, or plan communications about PA requirements.

## Criteria-Mapping Structure

Request Cigna's ECT PA criteria. Create a table mapping each criterion to the specific chart evidence that satisfies it. Add a separate section addressing the procedural failure: explain why PA was not obtained, why the clinical merits would have been satisfied, and (if applicable) why urgency excused the procedural lapse. A retrospective PA appeal that addresses both the procedural and clinical dimensions is far more likely to succeed than one that addresses only one.