Appeal a Cigna Denied Claim — Attorney-Drafted Letter Templates
By Tatiana Kadetskaya, Insurance Attorney
Cigna denies approximately 20 to 23% of health insurance claims. If your claim is among them, the appeal process is your legal right — and it works. When appeals cite Cigna's own Medical Coverage Policies and include strong physician documentation, the majority are overturned.
Cigna's appeal process has some specific quirks that catch people off guard: the address you send your appeal to depends on your plan type, EviCore may be involved in prior authorization denials, and Cigna requires a substantive appeal letter rather than a standardized form. This page covers all of it.
If Cigna just denied your claim, there is something you need to know before you do anything else: your denial may have been made by an algorithm that spent less than two seconds reviewing your case.
A lawsuit against Cigna alleges the company deployed an AI-based review system that spent an average of 1.2 seconds per claim — enabling the company to reject more than 300,000 claims in approximately two months. According to the lawsuit, Cigna physicians approved denials in bulk, often without reviewing individual patient records.
That is not medicine. That is automation. And it is something you can fight.
Cigna's Claim Denial Problem
Cigna is one of the largest health insurers in the United States, serving tens of millions of Americans through employer-sponsored plans, ACA marketplace plans, and Medicare Advantage. It also has a significant history of claims disputes.
The AI denial lawsuit is not isolated. Cigna has faced multiple legal challenges over its claims review processes, and patient advocates have documented a pattern of denials that prioritize speed and cost savings over individual medical review.
The company argues that its processes comply with the law and that denied claims are reviewed appropriately. But the evidence — including the lawsuit, patient testimony, and third-party data — tells a more complicated story.
What matters for you right now: however Cigna decided to deny your claim, you have the legal right to challenge that decision, and a well-structured appeal gives you a real chance of winning.
Why Cigna Denies Claims
Common reasons Cigna denies health insurance claims include:
Medical necessity. Cigna's internal clinical criteria determine whether your treatment qualifies as medically necessary. These criteria sometimes diverge from what your doctor — or mainstream medical guidelines — consider appropriate care.
Prior authorization required. Cigna requires prior approval for a wide range of services. If that approval was not obtained before treatment, the claim may be denied even if the treatment was clearly necessary.
Out-of-network care. If your provider is not in Cigna's network, your claim may be denied or paid at a sharply reduced rate.
Experimental or investigational. Cigna classifies some treatments as experimental even when they are in widespread clinical use. These denials are particularly worth challenging because the "experimental" label is often contestable.
Coverage exclusion. Cigna cites a policy exclusion to deny coverage, sometimes broadly interpreting exclusion language.
Coding or administrative errors. The provider billed with the wrong code, or a technical error in the submission triggers an automatic denial.
Your Legal Right to Appeal Cigna's Decision
Under federal law, you have guaranteed rights to challenge a Cigna denial:
180 days to appeal. You must file your written internal appeal within 180 days of receiving Cigna's denial notice. This is a hard deadline.
Right to a non-biased review. Cigna must assign your appeal to a reviewer who was not involved in the original denial decision.
Right to your claim file. Request a complete copy of all documents Cigna used to deny your claim. This is especially important with Cigna given the AI denial concerns — the file may reveal that your claim received no substantive human review.
External review rights. If Cigna upholds its denial after your internal appeal, you can request an independent external review. The external reviewer is not affiliated with Cigna, and if they overturn the denial, Cigna must pay your claim.
Expedited appeals. If your health situation is urgent, you can request an expedited review. Cigna must respond within 72 hours.
How the AI Denial Problem Changes Your Appeal Strategy
If your Cigna denial may have been generated algorithmically, your appeal strategy should account for this directly.
Request your full claim file and look for evidence of whether a physician actually reviewed your individual case. If the denial appears automated or templated, your appeal letter should explicitly note that the denial lacked individualized medical review — and that the ACA requires a full and fair review of your specific circumstances.
This is an argument that carries real legal weight with external reviewers, and it is one that most people never think to make.
Your Legal Right to Appeal Cigna's Decision
Under federal law, you have guaranteed rights to challenge a Cigna denial:
180 days to appeal. You must file your written internal appeal within 180 days of receiving Cigna's denial notice. This is a hard deadline.
Right to a non-biased review. Cigna must assign your appeal to a reviewer who was not involved in the original denial decision.
Right to your claim file. Request a complete copy of all documents Cigna used to deny your claim. This is especially important with Cigna given the AI denial concerns — the file may reveal that your claim received no substantive human review.
External review rights. If Cigna upholds its denial after your internal appeal, you can request an independent external review. The external reviewer is not affiliated with Cigna, and if they overturn the denial, Cigna must pay your claim.
Expedited appeals. If your health situation is urgent, you can request an expedited review. Cigna must respond within 72 hours.
How the AI Denial Problem Changes Your Appeal Strategy
If your Cigna denial may have been generated algorithmically, your appeal strategy should account for this directly.
Request your full claim file and look for evidence of whether a physician actually reviewed your individual case. If the denial appears automated or templated, your appeal letter should explicitly note that the denial lacked individualized medical review — and that the ACA requires a full and fair review of your specific circumstances.
This is an argument that carries real legal weight with external reviewers, and it is one that most people never think to make.
How to Appeal a Cigna Claim Denial — Step by Step
Step 1: Read the denial letter and identify the exact denial reason. Cigna's denial letters are required to state the specific reason for the denial. Highlight it. Everything in your appeal will be built around challenging that specific reason.
Step 2: Request your complete claim file from Cigna. Call Cigna member services and request all documents used in the review of your claim. Review this carefully for signs of automated decision-making, missing information, or misapplied criteria.
Step 3: Get your doctor to write a targeted support letter. Your physician's letter should directly address Cigna's stated denial reason — not just assert that the treatment is necessary. If Cigna said the treatment is not medically necessary, your doctor should explain why it meets Cigna's own criteria and any applicable clinical guidelines.
Step 4: Draft your appeal letter. A strong Cigna appeal letter should directly challenge their denial reasoning, cite clinical evidence, reference your policy language, and — if relevant — note that the denial lacked individualized medical review. Structure matters: an appeal that mirrors how Cigna's reviewers evaluate cases is far more effective than a letter that reads like a complaint.
Step 5: Submit and document your appeal. Send your appeal to the address on your denial letter by certified mail. Also submit through Cigna's online portal if available. Keep proof of every submission.
Step 6: Escalate to external review if needed. If Cigna denies your appeal, request external review immediately. Given Cigna's documented history with automated denials, external reviewers have overturned many decisions that Cigna initially refused to reverse.
Get an Attorney-Drafted Appeal Letter for Your Cigna Denial
Our templates are written by an attorney with over a decade of experience fighting insurance companies. They are structured to address the language and clinical criteria that Cigna uses in its review process.
👉 Browse appeal letter templates for Cigna claim denials →
Where to Send Your Cigna Appeal
Cigna's appeal routing depends on your plan type. The most reliable source for the correct address is always your own denial letter or EOB — use that address, not a generic one.
Standard fallback address (commercial plans — use only when no address appears on your denial): Cigna Healthcare Inc. National Appeals Unit (NAU) P.O. Box 188011 Chattanooga, TN 37422
EviCore denials (prior authorization reviewed by EviCore): EviCore Claim Appeals P.O. Box 5620 Hartford, CT 06102
By phone: Call the number on the back of your Cigna member ID card. Online: Through myCigna.com.
If your denial letter references EviCore or lists EviCore Healthcare as the reviewer, your appeal routes to EviCore, not the standard NAU address. Send your appeal to both addresses if you are uncertain and the deadline is approaching. Keep fax confirmation receipts — Cigna has been known to dispute receipt of appeals submitted without proof.
The Document That Determines Your Appeal: Cigna's Medical Coverage Policies
Cigna uses Medical Coverage Policies — similar to Aetna's Clinical Policy Bulletins and UHC's Coverage Determination Guidelines — to define what it considers medically necessary. These policies are available at CignaForHCP.com.
For any medical necessity denial, identify which Medical Coverage Policy Cigna applied, download it, and build your appeal around demonstrating that your treatment meets its criteria. Citing the policy by name and number in your appeal letter signals to the reviewer that you have done your homework — and that you are not going away.
Common Cigna Denial Types and How to Fight Each One
"Not medically necessary" — Identify the specific Medical Coverage Policy. Have your physician write a detailed letter directly addressing each criterion in the policy. Include peer-reviewed clinical studies and applicable guidelines from major medical societies.
👉 Medical Necessity Appeal Letter Template — Attorney-Drafted
"Out-of-network provider" — Document your grounds: emergency care, no accessible in-network alternative, or No Surprises Act protections. Include your physician's letter and evidence of network inadequacy if applicable.
👉 Out-of-Network Denial Appeal Letter Template — Attorney-Drafted
"Lack of prior authorization" — If EviCore reviewed the prior authorization denial, route your appeal to EviCore. Establish the medical urgency and any documentation showing authorization was requested or should not have been required.
👉 Prior Authorization Denial Appeal Letter Template — Attorney-Drafted
"Not covered / policy exclusion" — Request your full plan document and the specific exclusion language Cigna is applying. Ambiguous policy exclusions are legally challengeable.
👉 Policy Exclusion / Not Covered Appeal Letter Template — Attorney-Drafted
"Experimental or investigational" — Present peer-reviewed clinical evidence, Medical Coverage Policy analysis, and your physician's clinical reasoning. Cigna's experimental treatment policies frequently lag behind current clinical practice.
👉 Experimental Treatment Appeal Letter Template — Attorney-Drafted
Denial codes PR-1 or CO-167 — Verify deductible calculations (PR-1) or billing code accuracy (CO-167) with your provider's billing office before filing.
👉 PR-1 Deductible Appeal Letter — Attorney-Drafted
👉 CO-167 Mismatch Appeal Letter — Attorney-Drafted
If Your Cigna Internal Appeal Is Denied
You have the right to request external review by an Independent Review Organization (IRO) with no affiliation to Cigna. Their decision is legally binding. If external review is available after your appeal denial, Cigna's denial letter will outline the steps to initiate it — including a form to sign and return.
You may also file a complaint with your state's Department of Insurance at any point.
Start Your Cigna Appeal Today
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Frequently Asked Questions About Cigna Claim Denials
How do I know if Cigna used AI to deny my claim? Request your complete claim file. Look for templated language, generic denial reasoning that does not reference your specific medical history, or evidence that the review was conducted in seconds. If the file reveals that no substantive individual review occurred, note this explicitly in your appeal.
Can I appeal a Cigna denial for a medication? Yes. Pharmacy benefit denials — including prior authorization denials for prescription drugs — are fully appealable through the same process. If Cigna denied a medication your doctor prescribed, your appeal should include clinical evidence of why that specific medication is appropriate for your condition.
What if my Cigna plan is through my employer? Employer-sponsored plans are governed by ERISA. The appeals process is similar but the legal stakes of failing to appeal are higher — ERISA significantly limits your ability to challenge a denial in court if you did not first exhaust the internal appeals process.
***Appeal Templates LLC is not a law firm and does not provide legal advice. Our templates are self-help tools designed to help you exercise your existing legal rights.