Cigna CO-197 Prior Auth Denials in Behavioral Health

[Practice Letterhead]
[Date]

Cigna Behavioral Health Appeals
[Address from EOB]

Re: Appeal of CO-197 Denial
Member: [Patient Name]
Member ID: [Member ID]
Date of Service: [DOS]
Claim Number: [Claim #]
CPT / HCPCS: [e.g., 96132 - Neuropsychological testing evaluation, first hour; or H0015 - IOP]

To Whom It May Concern:

We are appealing the CO-197 prior-authorization denial for the above-referenced behavioral health service. The service was medically necessary, met Cigna's coverage criteria, and also invokes parity protections under the Mental Health Parity and Addiction Equity Act.

Clinical Indication:
[Patient], a [age] y/o [M/F] with [diagnosis, ICD-10], presented with [symptoms, severity, duration]. [For IOP/PHP: ASAM or LOCUS criteria indicate Level X care is clinically indicated given X, Y, Z factors.] [For neuropsych testing: clinical question to be answered by testing, prior treatment history, why outpatient therapy alone is insufficient.]

Documentation attached:
1. Admitting clinician's psychiatric evaluation
2. ASAM / LOCUS criteria worksheet
3. Prior outpatient treatment history demonstrating lower-intensity care was insufficient
4. Retro-authorization request filed with Evernorth on [date]
5. Cigna Medical Coverage Policy [number] excerpt showing criteria met

Parity Considerations:
Under MHPAEA, Cigna's prior-auth requirements for this behavioral health service cannot be more restrictive than comparable medical/surgical auth requirements. We respectfully request that Cigna apply the same retroactive authorization flexibility available for equivalent-intensity medical services.

[Clinician Name], the treating psychiatrist/psychologist, is available for peer-to-peer review at [phone].

Sincerely,
[Name]