ECT denied for failing step therapy 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 Step Therapy Before ECT — and How to Overcome It

Cigna's behavioral health policies commonly require that a patient has tried and failed a defined sequence of less-intensive psychiatric treatments before ECT will be authorized. This "fail first" or step-therapy requirement is the most frequent reason ECT is denied for patients whose psychiatrist considers them good candidates for the procedure.

### Why This Denial Is Appealable

Step-therapy requirements must be clinically reasonable. When a patient's condition is severe — acute suicidality, catatonia, inability to maintain adequate nutrition, or rapid deterioration — waiting through another medication trial is itself a clinical harm. Most states have enacted step-therapy exception laws requiring insurers to grant exceptions when (a) the required therapy is contraindicated, (b) the required therapy has already failed, or (c) the required therapy would cause serious harm. Check whether your state's law applies to your plan type (fully insured vs. self-funded ERISA plans). Additionally, under MHPAEA, Cigna cannot impose step-therapy requirements on mental health services that are more burdensome than comparable requirements for medical or surgical services.

### Federal Appeal Framework

• Internal appeal: File a written internal appeal with Cigna within the deadline stated on the denial notice. Request the specific clinical criteria and step-therapy protocol Cigna applied.
• External review (ACA §2719): Once internal remedies are exhausted, request independent external review. The standard window is approximately four months from your denial notice; verify your exact deadline on the Explanation of Benefits.
• Expedited review: Available when delay would seriously jeopardize health or the ability to regain maximum function. Decisions are generally required within 72 hours of the request.
• State insurance department: For fully insured plans, a step-therapy exception complaint to the state commissioner can run concurrently with the internal appeal.

### What to Gather

1. Diagnosis and severity documentation — current psychiatric evaluation with validated symptom scales from the chart showing severity of illness. 2. Medication trial history — a complete, dated log of every psychiatric medication tried: drug name, duration, dose range documented in chart, reason for discontinuation (inefficacy, intolerance, adverse event). 3. Evidence that required steps have been met or are inappropriate — if prior medication trials match or exceed Cigna's required steps, document this explicitly; if the required medications are clinically contraindicated or have already been exhausted, the prescriber should state that clearly. 4. Urgency documentation — if clinical deterioration makes further step-therapy delay unsafe, the prescriber's letter should address this directly. 5. Prescriber medical-necessity letter — the treating psychiatrist should map each criterion in Cigna's step-therapy protocol to a specific chart-documented fact and explain why ECT is the appropriate next step per current psychiatric practice guidelines (e.g., American Psychiatric Association guidelines).

### Criteria-Mapping Structure

Pull the exact language of each step-therapy requirement from Cigna's published behavioral health coverage policy. For each step, write a one-sentence response referencing the corresponding chart entry, date, and outcome. If a required step was skipped, explain the clinical rationale (contraindication, prior failure, urgency). Reviewers — including external reviewers — must respond to each mapped criterion, making this structure more effective than a narrative-only letter.