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Cigna is a national health insurer (now under the Evernorth umbrella for behavioral health) that provides coverage for detox, rehabilitation, outpatient programs, and medication-assisted treatment. Cigna’s medical necessity criteria for substance use treatment are founded on generally accepted standards like the ASAM Criteria and often MCG care guidelines. In many cases, Cigna has published its own “Cigna Standards and Guidelines/Medical Necessity Criteria” which incorporate ASAM principles ([PDF] CIGNA STANDARDS AND GUIDELINES/MEDICAL NECESSITY ...). Cigna also partners with behavioral health specialty organizations (like Evernorth Behavioral Health, previously known as Cigna Behavioral Health) to manage authorizations and care. Here’s what providers need to know about Cigna’s criteria, authorization process, and billing codes:
Cigna’s Clinical Criteria and ASAM Usage
Cigna’s published Medical Necessity Criteria document (2019 edition) explicitly covers all levels of mental health and substance use care. Within this, Cigna states it considers ASAM Criteria for Substance Use Disorders in making determinations ([DOC] Cigna-MCG-Behavioral-Health-Guidlines-09-2020.docx - Center Care). For example, Cigna uses ASAM criteria for guidance on substance use treatment placement ([DOC] Cigna-MCG-Behavioral-Health-Guidlines-09-2020.docx - Center Care), and they have criteria sections mirroring ASAM levels (their document has sections for Acute Inpatient Detox, Residential SUD Treatment, Partial Hospitalization, IOP, etc. mirroring ASAM levels of care).
What this means for providers: When you present a case to Cigna for authorization, you should frame it in ASAM terms. Cigna expects to see the patient’s needs described across dimensions and why a particular level of care is indicated.
Cigna’s criteria often use language like “the least intensive level of care that safely and effectively treats the patient” – which is exactly ASAM’s principle of matching severity to care setting (asam-criteria). They emphasize a multidimensional assessment (again ASAM-driven).
One unique feature: Cigna historically had something called the “Cigna Level of Care Assessment” and also utilized the CASII/LOCUS tools for mental health. For SUD, they rely on ASAM. In California, for instance, Cigna/Evernorth uses ASAM for all substance use reviews as required by state law (Evernorth Provider - Resources - Medical Necessity Criteria).
Therefore, ensure your documentation to Cigna covers:
Acute intoxication/withdrawal potential (Dimension 1).
Biomedical conditions (Dimension 2).
Emotional/behavioral conditions (Dimension 3).
Readiness to change (Dimension 4).
Relapse potential (Dimension 5).
Living environment (Dimension 6).
Detox (Withdrawal Management) – Cigna Criteria
Inpatient Detox (ASAM Level 4 or 3.7WM): Cigna will approve this when significant withdrawal symptoms are present or expected and require 24-hour medical management. Cigna’s criteria for “Acute Inpatient Drug and Alcohol Detoxification” likely include:
Presence of moderate to severe withdrawal signs (e.g., vital sign abnormalities, tremors, agitation for alcohol; yawning, dilated pupils, bone/joint aches for opioids).
A recent pattern of heavy substance use likely to cause severe withdrawal.
Risks such as history of withdrawal seizures or delirium.
Lack of a support system or ability to manage detox as an outpatient.
Additionally, if the patient has co-occurring medical conditions (heart disease, pregnancy, etc.) that complicate withdrawal, Cigna would lean toward inpatient detox as medically necessary.
Ambulatory Detox (ASAM Level 2-WM): If the withdrawal is relatively mild and the patient is reliable, Cigna might authorize detox on an outpatient basis. They may require a structured setting like a daily visit to a clinic or a day program. According to Cigna’s guidelines, they likely allow ambulatory detox if:
The patient is not at risk of life-threatening withdrawal.
The patient has someone to monitor them or can self-monitor.
The patient has no severe medical or psychiatric complications.
Cigna will often start by authorizing a few days of detox and require an update for extension. Ensure you call in or submit clinical updates promptly; their utilization reviewers often check daily progress.
Billing for detox (Cigna):
Use H0010 (sub-acute detox, residential inpatient) or H0011 (acute detox, residential inpatient) for facility-based detox. These are recognized by Cigna. If it’s a hospital setting, it might be bundled differently, but most standalone detox units use H0010/H0011.
H0012/H0013 for outpatient detox if applicable (though not commonly used, they are defined in coding systems for ambulatory detox). Cigna may simply have you bill E/M codes if outpatient detox is done in an office.
Cigna typically requires precert for all detox admissions – emergency or elective. So get that authorization.
Inpatient/Residential Rehabilitation – Cigna Criteria
Cigna differentiates between Acute Inpatient SUD Treatment (which might mean a hospital-based program) and Residential SUD Treatment in their criteria.
Acute Inpatient SUD Treatment (ASAM 3.7): This is used when a patient needs 24-hr care with some medical monitoring, but not the full hospital medical-surgical resources. Indications for Cigna:
Persistent withdrawal or medical issues even after detox (e.g., continued need for nursing care for a few days).
Severe psychiatric symptoms (like suicidal ideation, but not needing locked psychiatric unit) that co-occur with SUD.
Inability to function in a residential rehab due to medical complexity (but not severe enough for a medical floor).
However, often what Cigna calls “acute inpatient” might be more akin to what providers call residential rehab if it’s not in a general hospital. Cigna’s definition: “Inpatient Rehabilitation, Mentally Ill Chemical Abuser (MICA) or Dual Diagnosis treatment” might fall here.
Residential Rehabilitation (ASAM 3.5): Cigna’s criteria for residential SUD treatment emphasize:
Patient has ongoing substance use or high likelihood of relapse without 24-hr support. For instance, unable to maintain abstinence during IOP, or relapsed immediately after prior treatments.
Patient may have some stable co-occurring mental or physical issues, but nothing requiring hospitalization – the facility can manage these.
Motivation is sufficient to engage in rehab (if patient is not willing at all, forced residential rarely works, though Cigna doesn’t often deny on motivation if court-ordered or family-pressured, as long as they attend).
No safe alternative environment: If outpatient environment is too triggering or unsafe, that’s a strong criterion (ASAM Dimension 6).
Cigna will also want to see a treatment plan for residential care that includes multiple therapeutic activities per day (group, individual, family therapy, skill-building, etc.). They tend to authorize in blocks (maybe 7 or 14 days) and then require a review.
One feature: Cigna is known to be fairly strict on concurrent reviews. They might require a peer review call every week for residential to justify continuation. They’ll use ASAM continued stay criteria: is patient making progress, are there still triggers/needs present that require 24h care, etc. If a patient is just cruising in rehab without acute issues after some days, Cigna may push for step-down. So document ongoing justifications, like “patient still has strong cravings and only just starting to address underlying trauma; provider assesses high risk of leaving against medical advice to use if stepped down too early.”
Billing for residential rehab (Cigna):
H0018 – Covered for residential rehab (short-term). Cigna will authorize a certain number of days of H0018.
H0019 – If it’s a longer-term residential (maybe for youths or extended programs), they will cover H0019 as well, but often they treat H0019 similarly with regular reviews.
If billing on UB, use revenue code 1002 for residential treatment (chemical dependency) and attach the H0018 in the HCPCS field if required.
Authorization: needed for all residential admissions. Cigna often issues initial auth and subsequent extended auth reference numbers; include them on claims if possible.
Partial Hospitalization (PHP) & Intensive Outpatient (IOP) – Cigna Criteria
Cigna covers Partial Hospitalization Program (PHP) and Intensive Outpatient Program (IOP) as intermediary levels of care. They align with ASAM 2.5 and 2.1.
Cigna’s PHP criteria will allow PHP if:
The patient has significant symptoms or relapse risk needing near-daily intervention. Perhaps the patient just detoxed and still has cravings and a chaotic home, but can be safe overnight – PHP provides daily structure to reinforce sobriety.
Patient might have co-occurring psychiatric symptoms (e.g., depression, anxiety) that are moderate to severe but manageable in day program.
The patient does not need 24h supervision (no overnight danger).
The patient has transportation and can reliably attend.
Cigna’s IOP criteria:
Patient has moderate relapse risk or ongoing issues that cannot be managed with 1x weekly therapy alone. E.g., they continue to use if only in weekly therapy, or they need more peer support and skills practice.
Often used as step-down from PHP or residential, or step-up from outpatient. Document where the patient is coming from.
They must have a relatively stable living environment or at least one that won’t undermine IOP (if home is very triggering but patient refuses residential, IOP might be tried but Cigna might note the risk).
The patient should be medically stable (no acute withdrawal unmanaged, etc.) and not acutely suicidal or psychotic.
Cigna/Evernorth typically requires preauthorization for PHP and IOP. However, similar to Aetna, some states’ laws have forced insurers to ease up on requiring PA for these levels. IOP sometimes might not need formal PA at Cigna, but usually, Cigna still asks for notification and clinical info. It’s best practice to obtain an auth number for tracking.
Also, if the employer plan is using a vendor (for example, some Cigna plans outsource behavioral health to Behavioral Health Systems or Evernorth), the process might vary. But the criteria remain standard.
Billing for PHP/IOP (Cigna):
PHP: Use HCPCS S0201 or CPT H0035 as per Cigna’s guidance. Many Cigna plans list S0201 for PHP day. Authorization will often be given like “5 days/week x 2 weeks = 10 units of S0201.”
IOP: Use HCPCS H0015. Cigna’s 2019 criteria doc references IOP in section at page 75 (which likely correlates to the ASAM IOP criteria), meaning they fully recognize this code/level. Cigna might authorize IOP in terms of number of weeks (e.g., 3 weeks of IOP, 3 days/week = 9 sessions).
Group vs individual therapy in IOP: IOP typically includes group therapy. If you try to bill individual therapy on the same day as IOP, Cigna will probably not pay separately (considered part of the IOP day rate).
Some Cigna plans might allow a facility charge plus professional charges for PHP. If in a hospital setting, they might want revenue codes (0913 for PHP) and then separate physician billing for visits. In freestanding, S0201 covers it all.
Documentation for PHP/IOP should be submitted to Cigna possibly at start, mid-point, and end. They want to see that the patient is benefiting or if not, that you are considering a different level (if patient keeps using during IOP, maybe needs residential).
Medication-Assisted Treatment (MAT) – Cigna Criteria
Cigna strongly supports MAT as part of SUD treatment. Cigna was one of the insurers involved in the landmark Wit v. UBH case indirectly, which highlighted the importance of covering treatments per ASAM and not imposing undue restrictions. As a result, Cigna (and now Evernorth) covers buprenorphine, methadone, naltrexone, etc. in line with national guidelines.
Preauthorization for MAT:
Buprenorphine: Cigna has removed prior authorization for Suboxone/Subutex in most plans to comply with state laws and facilitate access. They may have quantity limits (like 16 mg/day threshold, above which a PA is needed with rationale).
Methadone (OTP): Cigna covers methadone for OUD through OTP clinics. Many Cigna plans didn’t historically contract with OTPs, but that’s changing. If a member is using their insurance for OTP, Cigna likely needs an authorization for the episode of care, though some plans may have a case rate. Check if Evernorth has an OTP network in your area.
Naltrexone (oral/injectable): Usually no PA for Vivitrol, but sometimes they require an authorization for medical benefit coverage. It’s typically easily obtained – just show OUD or alcohol use disorder diagnosis and that patient has no contraindications.
Combination of MAT with therapy: Cigna doesn’t mandate therapy attendance as a condition for medication coverage, but they do encourage it. When reviewing higher levels of care, mention if MAT is being used or planned, as that shows adherence to best practices (Cigna likes to see comprehensive plans).
Billing for MAT (Cigna):
Buprenorphine: Prescription coverage through pharmacy. No billing by provider for the med, just the office visit. If doing an induction in an office, you bill your time via E/M. Cigna pays E/M + psychotherapy if provided (they might even pay a longer E/M if prolonged service). Use appropriate X-waiver modifier if they require (though after June 2023, X waiver no longer needed legally, but some systems still track for a bit).
Methadone (OTP): If billing Cigna, use H0020 per day or the Medicare OTP G-codes if instructed. Confirm with Cigna if they require one weekly claim or daily. They might follow Medicare’s approach.
Tele-MAT: Cigna covers telehealth for MAT. Use the 95 modifier for telehealth E/M for buprenorphine follow-ups; they’ve been reimbursing those in parity with in-person.
Drug screens: As part of MAT, random drug screens are covered, but Cigna might limit frequency (e.g., 8 per month max for high risk). Use proper codes and only necessary frequency to avoid denials.
Prior Authorization and Utilization Management with Cigna
Preauthorization is required for:
Inpatient detox and rehab admissions.
Residential rehab admissions.
Partial Hospitalization (PHP).
Likely Intensive Outpatient (IOP) – though some Cigna/Evernorth plans might only require notification for IOP, it’s safest to get an auth.
Some outpatient services like psychological testing or higher-cost meds might need auth, but standard therapy or med management visits do not.
To get authorization with Cigna:
Call the number on back of card (often Cigna Behavioral Health/Evernorth line).
You may also submit via their provider portal (CignaforHCP or Evernorth provider portal).
Provide clinical information possibly to a care manager or via fax forms.
Cigna often assigns a “Care Manager” once a patient is in a higher level of care. That person may reach out to you weekly for updates. Engage with them; they can become allies in securing ongoing days or coordinating step-downs.
Concurrent Reviews: For inpatient/residential, expect at least weekly reviews. For PHP, maybe weekly as well. IOP perhaps every 2 weeks. Provide objective evidence of progress (or lack thereof and justification for more time).
Peer Reviews: If Cigna ever issues a denial or reduction (e.g., “We approve 5 more days, then step down to IOP”), you can request a peer-to-peer with a Cigna physician (usually a psychiatrist or addiction specialist). Come prepared with specifics on why the higher level is still needed. For instance, “Patient has been in residential 10 days, still experiencing strong cravings and has not yet secured housing for discharge – stepping down now would likely lead to relapse; ASAM criteria indicate continue 3.5 level until stability improves.”
Documentation: Always include:
Dates of last use and current sobriety status.
Any acute incidents (craving episodes, therapy breakthroughs, medical issues) to show need for continued care.
Plan for transition (Cigna likes to know you’re planning next level – e.g., “We are arranging IOP after discharge on X date” – this can sometimes help get a few extra days to line up aftercare).
Cigna/Evernorth also emphasizes family or support involvement. Their criteria mention including family in treatment if appropriate. Document attempts at that – it shows a comprehensive approach which Cigna expects from a quality standpoint.
Appeals: If disagreements happen, use Cigna’s appeals. They have internal appeals and you can also file complaints to external review if needed. Cigna’s compliance with parity means if a service is denied for not meeting criteria, you can appeal by showing how criteria were actually met per ASAM. External reviewers almost always uphold ASAM-aligned arguments.
Billing Codes and Claims for Cigna
Cigna’s billing requirements are similar to other insurers but here are some pointers:
Make sure you use Cigna’s payer ID (which is often 62308 for behavioral, or check card).
For facility billing, ensure Revenue Codes align with HCPCS:
Rev 0100-series for detox/residential,
0900-series for PHP/IOP.
Cigna often requires providers to include their facility NPI and sometimes attending provider NPI on UB claims. Missing info can cause rejections.
Key codes:
H0001 (assessment), H0004 (counseling), H0005 (group) – recognized if part of a program.
H0038 for peer recovery support – Cigna might cover if part of state mandates (e.g., some Medicaid plans).
For dual-diagnosis inpatient, sometimes both psych DRG and SUD rehab codes might come into play. Coordinate if patient is on a psych unit vs SUD unit – Cigna will want one primary authorization.
Modifiers:
Use UA/UB if required for certain state contracts (Cigna Medicaid often).
Use GT/95 for telehealth as needed.
Use TG for complex/high level if required (some insurers use TG to indicate adult residential vs no modifier for standard – Cigna doesn’t widely use this, but check contract).
Claim follow-up: Cigna is generally timely, but if a claim denies:
Check if authorization was on file. If not, contact them – sometimes they might retro-authorize if there was an error.
If coded incorrectly, fix and resubmit (e.g., used wrong place of service code).
If partial paid (like they paid only 14 of 21 days), they might have closed auth early. Call and if needed, appeal for remaining days.
In summary, Cigna’s requirements mirror industry standards with a strong lean on ASAM Criteria. Prior authorization and proper coding are crucial. By understanding their criteria and speaking Cigna’s language in documentation (e.g., quoting their guidelines about matching patients to least restrictive care, etc.), providers can secure approvals. Also, leveraging internal resources like BehaveHealth’s guides on insurance billing can equip provider offices with tips specific to Cigna – such as knowing that Cigna uses ASAM and will apply it for both admission and continued stay reviews.
Using these strategies, providers can work effectively with Cigna/Evernorth to ensure patients get the needed addiction treatment services authorized and that claims are paid accurately. Remember that Cigna, like its peers, is bound by mental health parity law – any denial must be on solid clinical grounds, and you have the right to challenge decisions that don’t align with generally accepted standards (which today are essentially the ASAM criteria for SUD). With detailed documentation and persistence, you can navigate Cigna’s processes successfully.