Cigna Removes Prior Authorization from More Services

Cigna Healthcare has removed 600 additional codes for medical services from prior authorization requirements. Since 2020, the health plan has removed more than 1,100 medical services from prior authorization requirements.

In the latest effort, the services being removed from prior authorization requirements include a wide range of tests, treatments and medical equipment, including more than 100 surgical codes, nearly 200 genetic testing codes, durable medical equipment, and orthoses and prosthetics, a Cigna spokesperson said. But no prescription medications have been removed from prior authorizations.

David Brailer, M.D.

“We’ve listened attentively to our clinician partners and are deliberately making these changes as a result. We will continue to hold ourselves accountable for this important work and look forward to building on this momentum in the future,” David Brailer, M.D., executive vice president and chief health officer, The Cigna Group, said in a press release.

With this update, prior authorization now applies to less than 4% of medical services for most Cigna Healthcare customers. Cigna Healthcare will also remove prior authorization for nearly 500 codes for Medicare Advantage plans later this year.

Cigna’s move follows a similar one earlier this month from United Healthcare, which will remove almost 20% of prior authorization requirements. Beginning Sept. 1, 2023, some codes will be removed from UnitedHealthcare Medicare Advantage, UnitedHealthcare commercial, UnitedHealthcare Oxford and UnitedHealthcare Individual Exchange plans. Other codes will be removed Nov. 1, 2023. Changes for UnitedHealthcare Community Plan will take place on Nov. 1, 2023, according to the company.

United Healthcare also said that in 2024, it will implement a national Gold Card program for provider groups that meet eligibility requirements, which will allow for a more simple process for prior authorizations.

Prior authorization has come under fire by doctor groups and members in Congress. The American Medical Association says that prior authorization is overused and places a burden on doctors. Physicians and their staff spend almost two days a week completing prior authorizations, according to the AMA.

In July, the House Ways and Means Committee conducted a mark up of a bill that would address prior authorization in Medicare. The bipartisan bill would establish an electronic program for prior authorizations and expand patient protections. The Improving Seniors’ Timely Access to Care Act unanimously passed the House last Congress and was cosponsored by a majority of members in the Senate and House of Representatives.

“I commend the efforts of the House Ways and Means Committee for investing in our legislation along with other patient-centered reforms in this cost-effective package. My bipartisan, bicameral co-leads and I will continue to work towards advancing the Improving Seniors’ Timely Access to Care Act to the finish line in Congress and through federal health agencies,” U.S. Senator Roger Marshall, M.D. (R-Kan.) said in a press release.

Marshall and other senators recently sent letters to the Centers for Medicare & Medicaid Services (CMS) urging the agency to quickly finalize a set of proposed rules for prior authorization with Medicare Advantage.

These moves were taken after the Officer of Inspector General of the Department of Health and Human Services issued a report in April 2022. They found that 13% of prior authorization denials by Medicare Advantage plans were for benefits were covered under Medicare, such as MRIs and inpatient rehabilitation. Plans tended to use clinical criteria that are not contained in Medicare coverage rules,

Additionally, the OIG released in July 2023 a report about prior authorization denials in Medicaid Managed Care. They found that Medicaid managed care organization denied one out of every eight requests for the prior authorization of services in 2019. And 12 plans had prior authorization denial rates greater than 25%, which the OIG said was twice the overall rate.