Cigna (Evernorth) denial appeals
Cigna serves a large employer-sponsored book and runs Medicare Advantage in select markets. The company's automated 'PXDX' review process for high-volume denials has been the subject of recent litigation and regulatory scrutiny.
Cigna (Evernorth) reported claim denial rates, by state
In-network denial rate each Cigna (Evernorth) marketplace issuer reported to CMS (Transparency in Coverage PUF; two-year lag; includes administrative denials). Click a state for the full report card.
- ArizonaCigna HealthCare of Arizona, Inc16.2%
- FloridaCigna Health and Life Insurance Company20.0%
- FloridaCigna HealthCare of Florida, Inc.n/a
- GeorgiaCigna HealthCare of Georgia, Inc.17.7%
- IllinoisCigna HealthCare of Illinois, Inc.26.0%
- IndianaCigna Health and Life Insurance Company19.6%
- MississippiCigna Health and Life Insurance Company27.7%
- North CarolinaCigna HealthCare of North Carolina, Inc.16.1%
- South CarolinaCigna HealthCare of South Carolina, Inc.n/a
- TennesseeCigna Health and Life Insurance Company20.3%
- TexasCigna HealthCare of Texas, Inc.21.7%
- UtahCigna Health and Life Insurance Company21.3%
If Cigna (Evernorth) denied a claim or service, you can appeal, and the plan must give you its file and the criteria it used. Filing windows by plan type: at least 180 days (employer self-funded plans); at least 180 days (insured and Marketplace plans); 65 days from the notice (Medicare Advantage); 65 days from the notice (Part D). The date printed on your denial notice controls; it can only be later than these floors, never earlier.
Cigna (Evernorth) appeals: the rule, the deadline and the next level, by plan type
Which row applies depends on the plan you hold, not on Cigna (Evernorth)'s brand. Your ID card, the Summary Plan Description and the denial letter say which.
| Plan type | Rule that governs | File your appeal within | The plan must answer | If the plan says no again |
|---|---|---|---|---|
| Employer self-funded plan (ERISA) Most large employers. The employer pays the claims and hires the carrier to administer them; the Summary Plan Description says self-funded or self-insured. | ERISA § 503 (29 U.S.C. § 1133) and the claims-procedure rule, 29 CFR 2560.503-1. Federal external review under 45 CFR 147.136(d) for non-grandfathered plans. | At least 180 days from the adverse benefit determination (29 CFR 2560.503-1(h)(3)(i)). | Urgent care: 72 hours. Pre-service: 30 days. Post-service: 60 days (29 CFR 2560.503-1(i)(2)). | Federal external review by an accredited independent review organization, requested within 4 months of the final internal denial (45 CFR 147.136(d)); then a civil action under ERISA § 502(a). State insurance departments do not regulate self-funded plans; the U.S. Department of Labor does. |
| Fully insured employer, individual or Marketplace plan The carrier holds the risk and is licensed in your state. Small employers and almost all individual and HealthCare.gov plans. | 45 CFR 147.136 (Public Health Service Act § 2719), which applies the 29 CFR 2560.503-1 procedures and adds state external review; state insurance law on top. | At least 180 days from the denial (45 CFR 147.136(b); 29 CFR 2560.503-1(h)(3)(i)). | Urgent care: 72 hours. Pre-service: 30 days. Post-service: 60 days. Prior-authorization decisions by Marketplace issuers from 2026: 72 hours expedited, 7 calendar days standard (CMS-0057-F). | External review through your state's process, or the federal process where the state has none, generally within 4 months of the final internal denial (45 CFR 147.136(c), (d)). The state insurance department and its Consumer Assistance Program take complaints. |
| Medicare Advantage (Part C) A private plan that replaces Original Medicare. The card says Medicare Advantage, HMO, PPO or PFFS. | 42 CFR Part 422, Subpart M (§§ 422.560 to 422.634). Coverage decisions must follow Original Medicare rules (42 CFR 422.101). | 65 calendar days from the date on the denial notice to request the plan's reconsideration (42 CFR 422.582, as amended effective 1 January 2025). | Expedited: 72 hours. Standard pre-service: 30 days (7 days for Part B drugs). Payment: 60 days (42 CFR 422.590). | If the plan does not fully reverse itself it must send the case to the Independent Review Entity on its own (42 CFR 422.592); then an ALJ hearing when the amount in controversy meets the annual threshold, the Medicare Appeals Council and federal court. State external review does not apply. |
| Medicare Part D (drug plan or MA-PD) A stand-alone drug plan or the drug benefit inside a Medicare Advantage plan. | 42 CFR Part 423, Subpart M; exceptions under 42 CFR 423.578. | 65 calendar days from the date on the notice to request a redetermination (42 CFR 423.582, as amended effective 1 January 2025). Formulary, tiering and step-therapy exceptions need the prescriber's supporting statement (§ 423.578). | Redetermination: 7 calendar days standard, 72 hours expedited (42 CFR 423.590). Coverage determinations: 72 hours standard, 24 hours expedited, once the prescriber's statement is received (§§ 423.568, 423.572). | Independent Review Entity reconsideration on your request within 65 days of the redetermination notice (§ 423.600); then ALJ, Council and court. |
What you can demand. The plan must give you the claim file, the internal rule or criterion it relied on, and the identity of the reviewer, free of charge, on request (29 CFR 2560.503-1(h)(2)(iii), (m)(8)).
How to open the appeal. Cite ERISA § 503 and 29 CFR 2560.503-1 in the opening paragraph: request the claim file and the specific criteria relied on, and note the 30-day (pre-service), 60-day (post-service) and 72-hour (urgent) decision clocks.
What you can demand. The plan must give you the claim file, the criteria it applied and any new evidence or rationale before the final decision, free of charge (45 CFR 147.136(b)(2)(ii)(C); 29 CFR 2560.503-1(h)(2)(iii)).
How to open the appeal. Cite 45 CFR 147.136 and 29 CFR 2560.503-1: request the claim file and the criteria, note the decision clocks, and name the state external-review right.
What you can demand. The plan may not apply internal criteria that are more restrictive than Medicare's national and local coverage determinations, and must decide medical necessity on your individual circumstances (42 CFR 422.101(b), (c)). You can ask for the case file and the criteria used.
How to open the appeal. Cite 42 CFR 422.582 and 422.101(c): the plan must decide on your individual circumstances under Medicare coverage rules, and must forward an unfavorable reconsideration to the IRE itself.
What you can demand. The exception turns on the prescriber's statement that the formulary alternative would be less effective or would harm you (42 CFR 423.578(b)(5)).
How to open the appeal. Cite 42 CFR 423.578 and 423.582 and attach the prescriber's supporting statement written to the exception standard.
In the CMS Transparency in Coverage data for plan year 2026 (2024 claims), the 12 Cigna (Evernorth)-family Marketplace issuer filings across 11 states reported in-network claim denial rates from 16.1% to 27.7% (median 20.2%). Issuer-level, self-reported, HealthCare.gov plans only; a denial includes duplicate and administrative denials.
See every Cigna (Evernorth) issuer by state →Primary sources for this table
- 29 CFR 2560.503-1, ERISA claims procedure
- 45 CFR 147.136, internal claims and appeals and external review
- U.S. Department of Labor, EBSA, health benefit claims and appeals
- HealthCare.gov, how to appeal an insurance company decision
- CMS-0057-F, prior-authorization decision timeframes from 2026
- 42 CFR Part 422, Subpart M, Medicare Advantage grievances, organization determinations and appeals
- 42 CFR 422.101, Medicare Advantage coverage rules and medical-necessity decisions
- Medicare.gov, claims and appeals
- 42 CFR Part 423, Subpart M, Part D coverage determinations, redeterminations and reconsiderations
- 42 CFR 423.578, Part D exceptions process
Windows are federal floors or the rule as written; the denial notice controls. Reviewed 13 September 2026. General information, not legal advice; Apellica is not a law firm.
Patterns we see on Cigna denials
Algorithmic ('PXDX') denials
A class of Cigna denials are reviewed only briefly by physicians under an internal automated workflow. Appeals that demand a documented manual clinical review have produced strong reversal rates.
Urgent designation compresses timelines
Cigna honors the urgent flag aggressively when the prescribing doctor signs off. This drops the response window from 30 days to 72 hours.
Out-of-network billing disputes
Cigna's out-of-network reimbursement methodology has shifted multiple times. Rebilling using fair-market reasonable-and-customary data unlocks recoveries on cases coded as 'paid in full.'
Internal level 1 (30 days standard / 72h urgent), then independent external review.
180 days from initial denial for level-1 appeal.
How we file Cigna appeals
Cigna's peer-to-peer review window is short, usually a 24-48h scheduling block. We coordinate this directly with the prescribing physician.
Denied by Cigna? Let's appeal it.
Two-minute micro intake. We confirm fit and reply within one business day. No card at intake. You only pay if the carrier reverses the denial.
Start Your AppealDisclaimer: information shown is general guidance, not legal advice or a guarantee of outcome. Individual case outcomes depend on documentation, timing, and the specific terms of your plan.