Cigna Claim Denied: How to Appeal Your Cigna Health Insurance Decision

Cigna Denied Your Claim: Here's What to Do

Cigna is one of the largest health insurance providers in the United States, serving millions of individuals and employer groups. If Cigna has denied your health insurance claim, you are not alone — and you are not out of options. Federal law under the Affordable Care Act (ACA) guarantees you the right to appeal any adverse benefit decision, including claim denials, coverage denials, and prior authorization refusals. And critically, you have the right to an independent, external review at no cost.

This guide walks you through Cigna's internal appeal process, the external review process, your ACA rights, and how to escalate to state insurance regulators if needed.

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Why Cigna Denies Claims

Understanding the reason for your denial is the foundation of an effective appeal. Cigna's most common denial reasons include:

Medical necessity denials. Cigna determines that the service, procedure, or medication was not medically necessary based on its clinical coverage policies. This is the most common and most frequently reversed type of denial.

Prior authorization not obtained or denied. Many services require Cigna's advance approval. If authorization was not obtained, or if Cigna denied the prior authorization request, coverage may be denied.

Out-of-network provider. If you received care from a provider outside Cigna's network without an approved exception, Cigna may deny or reduce payment.

Experimental or investigational treatment. Cigna may classify a treatment as experimental and therefore excluded under your plan.

Coordination of benefits. If Cigna believes another insurer should pay first, it may deny or reduce your claim pending coordination of benefits information.

Coding errors. The healthcare provider submitted a billing code that does not match the service performed or that triggers an automatic denial flag.

Lack of documentation. Cigna requested additional medical records or documentation from your provider that was not received.

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Your Rights Under the ACA and Federal Law

The Affordable Care Act (ACA) and its implementing regulations — particularly the Department of Labor's claims and appeals regulations at 29 CFR § 2560.503-1 and 45 CFR § 147.136 for non-grandfathered plans — give you the following guaranteed rights:

• Right to a written denial: Cigna must provide a written Explanation of Benefits (EOB) specifying the reason for denial, the specific plan provision relied upon, and the criteria used to make the decision.
• Right to request the claims file: You are entitled to request and receive, free of charge, all documents relevant to the claim decision.
• Right to an internal appeal: You may appeal any adverse benefit determination to Cigna.
• Right to an external review: After exhausting internal appeals, you are entitled to an external review by an Independent Review Organization (IRO) certified by your state. For most denials involving medical judgment, this right kicks in immediately.
• Right to continue coverage during an appeal: For ongoing treatment, you may be entitled to continuation of coverage during the appeal process.

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Cigna's Internal Appeal Process

Step 1: Request Your Denial Documentation

Before filing your appeal, request the following from Cigna:

• The complete Explanation of Benefits (EOB)
• A written explanation of the specific reason for denial, including the clinical criteria used
• A copy of your complete claims file (all documents considered in making the decision)
• The Cigna clinical policy bulletin (CPB) used to evaluate medical necessity

You can request your complete claims file by calling the number on the back of your Cigna ID card or through the myCigna online portal at mycigna.com.

Step 2: File Your Internal Appeal

Deadline: You generally have 180 days from the date of the adverse benefit determination to file an internal appeal. Check your Summary Plan Description (SPD) for the exact deadline.

How to file:

• Submit your appeal in writing (keep a copy).
• Address it to Cigna's Appeals Department. The address will be in your denial letter or on the back of your Cigna ID card.
• You can also file online through myCigna or by fax. Always get a confirmation.

Your appeal should include:

• Your name, Cigna ID number, and the claim/authorization number from the EOB
• A clear statement that you are filing a formal appeal
• Your grounds for appeal (why the denial is incorrect)
• A letter of medical necessity from your treating physician explaining why the service was medically necessary for your specific condition, citing clinical guidelines
• Medical records supporting the claim
• Relevant peer-reviewed medical literature, clinical guidelines (American Medical Association, specialty society guidelines), or FDA approval information if disputing an experimental treatment classification
• A signed HIPAA authorization if submitting records from a third party

Timelines for Cigna's response:

• Urgent/expedited appeals (involving urgent medical situations): Decision within 72 hours
• Pre-service appeals (before a service is performed): Decision within 30 days
• Post-service appeals (after a service has already been performed): Decision within 60 days

Step 3: The Cigna Peer-to-Peer Review

Before filing a formal appeal, your doctor can request a peer-to-peer review with the Cigna medical director who made the denial decision. This is an informal, physician-to-physician conversation that can sometimes resolve prior authorization and medical necessity denials quickly. Ask your doctor's billing or prior authorization staff to arrange this.

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External Review: Your Most Powerful Option

If Cigna upholds its denial after internal appeal (or in certain situations, even before completing internal appeals), you are entitled to request an external review by an Independent Review Organization (IRO). This is one of the most powerful rights the ACA gives you.

Key facts about external review:

• It is free for you.
• The IRO's decision is binding on Cigna.
• The IRO is independent — it is not paid by or affiliated with Cigna.
• You have 4 months from receiving Cigna's final denial to request external review.
• For urgent/expedited situations, external review can be completed within 72 hours.

How to request external review:

• Your denial letter must include information on how to request external review.
• You can request it directly through your state insurance department, or Cigna may have a process to initiate it.
• Check your state insurance department's website for information on approved IROs in your state.

Federal external review applies to fully-insured employer group plans and individual market plans. Self-funded employer plans follow a federal external review process administered through the Department of Labor.

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Cigna Complaints to State Insurance Departments

If Cigna is failing to comply with state insurance laws — for example, by failing to respond to your appeal within required timeframes, by denying a claim for a mandated benefit, or by engaging in bad faith claims handling — you can file a complaint with your state insurance department.

Every state has an insurance regulator. Key states with active insurance consumer protection divisions include:

• California: California Department of Insurance — insurance.ca.gov
• New York: New York State Department of Financial Services — dfs.ny.gov
• Texas: Texas Department of Insurance — tdi.texas.gov
• Florida: Florida Department of Financial Services — myfloridacfo.com

Find your state's insurance department at the NAIC directory: naic.org/state_web_map.htm

State regulators can investigate Cigna's handling of your claim, require Cigna to respond, and in cases of systemic violations, take regulatory action including fines.

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Common Mistakes When Appealing Cigna Denials

Not getting your doctor to write a specific letter. A generic "patient needs this treatment" letter rarely wins an appeal. Your doctor's letter must be specific: explain the diagnosis, the clinical rationale for this specific treatment, why alternatives have failed or are inappropriate, and cite relevant clinical guidelines.

Missing the appeal deadline. The 180-day internal appeal deadline is typically firm. Missing it may forfeit your appeal rights. File promptly.

Not requesting the complete claims file. You cannot effectively challenge a denial without knowing exactly what evidence Cigna used. Request the full file.

Accepting a denial for an in-network service as final. If a Cigna-network provider billed Cigna and Cigna denied, this is your right to pursue. The provider may also advocate on your behalf.

Not pursuing external review. Many people give up after the internal appeal is denied. External review is free, independent, and reverses a significant proportion of upheld denials — particularly for medical necessity and experimental treatment cases.

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Draft Your Cigna Appeal Letter with ClaimBack

Writing a Cigna appeal letter that incorporates the right clinical language, the correct ACA regulatory references, and a persuasive medical argument requires time and precision. ClaimBack at claimback.app generates professional, structured Cigna appeal letters tailored to your specific denial type. Whether your denial is based on medical necessity, experimental treatment, prior authorization, or out-of-network issues, ClaimBack produces a letter that gives you the best chance of success.

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Conclusion

A Cigna claim denial is not the last word. Between the internal appeal process, peer-to-peer review, external review by an independent organization, and state insurance department complaints, you have multiple powerful tools available — most of them free. The key is to act within deadlines, gather strong medical evidence, and make a clear, evidence-based argument for why the denial was wrong. Start your appeal today, use ClaimBack at claimback.app to help draft your letter, and exercise the rights the ACA guarantees you.