Cigna mri coverage policy

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To determine who qualifies, Cigna evaluates physician performance using criteria that may include quality of care, quality of service, and appropriate use of medical services. Formulary Some patient advocates and independent pharmacists contend that drug formularies limit patient treatment options and can inhibit therapy.

In particular, media attention has focused on certain drugs not being included on formularies. Patient advocacy groups are seeking coverage for all FDA-approved drugs, regardless of whether they are approved for the treatment for which they are being prescribed.

Legislative attacks are under way. The Susan Horn Study , concluded that use of formularies increased use of health care services, which resulted in lower quality and increased costs. The Cigna formulary—a list of drugs covered by a member's benefit plan—was developed to assure quality and cost effective drug therapy. Drugs included in our formulary are carefully selected by physicians and pharmacists for their efficacy, and the formulary is reviewed and updated regularly.

This process allows our members to benefit on an ongoing basis from advances in pharmaceutical science that can dramatically improve the quality of people's lives. Hospitals have used drug formularies in the same way for many years. The Cigna national drug formulary contains 1, FDA-approved brand name and generic drugs. These drugs are placed on the formulary by the Cigna Pharmacy and Therapeutic Committee, which meets quarterly and is composed of physicians and pharmacists.

The Cigna Pharmacy and Therapeutic Committee reviews all FDA-approved drugs, groups them by therapeutic function, and then, within each group, compares their relative therapeutic effectiveness and potential side effects. Only when two or more drugs are determined to be therapeutically equivalent does cost become a consideration. Cost is an appropriate and necessary consideration, since drug prices have risen three times faster than the rate of inflation over the last decade. We offer a variety of formulary structures, depending on the level of prescription drug coverage your employer chooses to offer.

Our Two-Tier Formulary covers generic drugs and preferred brand-name drugs that do not have generic equivalents slightly higher copayment required. Our Three-Tier Formulary covers generics, preferred-brand, and non-preferred brand drugs medications that have generic equivalents or one or more preferred-brand options available at a higher copayment level. Your employer can tell you which formulary program you participate in or you can call Member Services.

You can also review your specific formulary for covered medications online. Local Cigna plans may modify the national formulary to take into consideration local prescribing practices. If a physician wishes to prescribe a drug that is not on the formulary, the physician or a member may seek an exception to the formulary for coverage of a non-formulary drug.

It has resurfaced again in several state legislatures and at the federal level. Critics of managed care are making the argument that when a health plan denies coverage for a treatment or procedure, it is a medical decision—because the health plan is deciding what treatment it will cover—and should be subject to medical malpractice liability. The underlying assumption is that treatment will not be given unless the health plan will pay for it.

Health plan medical professionals make coverage determinations based on the terms of a member's particular benefit plan.

Health plan medical directors use utilization management guidelines to assist in making such coverage determinations, but they are used as just that—guidelines—and are not a substitute for a clinician's judgment. The utilization management guidelines are a set of optimal clinical practice benchmarks for a given treatment with no complications and are based solely on sound clinical practices.

The Cigna utilization management guidelines are reviewed by each local health plan's quality committee, composed of Cigna-participating physicians practicing in the area, and are modified to reflect local practice. The guidelines are applied on a case-by-case basis. Mandated Benefits Mandated benefits require managed care companies and insurers by law to provide coverage for specific treatments and procedures and may set durational limits on coverage e.

These laws, typically enacted by state legislatures, apply only to HMOs and insured plans, and do not apply to self-insured plans. Federal mandates, however, apply to all employer-provided plans, whether insured or self-insured. One of the biggest concerns with mandated benefits is that they increase the cost of health care coverage. Some recent examples of mandated benefits include coverage for diabetic supplies, equipment and education, prostate screening antigen PSA testing for prostate cancer, bone densitometry for osteoporosis, breast reconstructive surgery following a mastectomy, and mastectomy length-of-stay requirements.

We are opposed to the government determining specific benefits to be included in managed care and insurance contracts. We believe that the marketplace should determine the benefits available to health plan participants. Mandatory Point-of-Service Legislative mandates that would require all HMOs to offer a point-of-service plan—a plan that offers participants the option to choose out-of-network providers for covered services—have been introduced in several states and have been enacted in several others.

Legislators are attempting to guarantee that consumers are offered a health care coverage option other than a traditional HMO. We oppose legislative mandates that would require all HMOs to offer an out-of-network benefit. This mandate would increase costs for employers and members and would eliminate traditional HMOs as a product offering in the marketplace.

Point-of-service plans are already an option widely available in the marketplace. Maternity Care We care about the health and well-being of our members. We also provide expectant mothers with educational materials, including a handbook on pregnancy and infancy. If a high-risk pregnancy is identified, the woman will be followed throughout the pregnancy by a case manager who is a registered nurse.

The case manager, trained in obstetrics, works with the doctor and member to develop and carry out an appropriate treatment plan that fosters a successful pregnancy and childbirth.

The time a mother and baby spend in the hospital after delivery is a medical decision. Shorter or longer lengths of stay may be approved at the request of the attending physician. Medically necessary home care services are available following discharge from the hospital. Home care nurses are trained to give a full assessment of the mother's and baby's health as well as answer any questions.

Many physicians find that home care is the most effective way to follow up with a new mother since it enables a complete assessment of both health and home environmental issues.

Mental Health Parity In , mental health advocates were successful in the passage of federal legislation that requires employers who provide mental health coverage to apply the same annual and lifetime dollar limits to the mental health benefits as are applied to benefits for physical illness. Mental health advocates are now seeking state legislative mandates that would require mental health coverage be provided in all health plans at the same level of benefits as physical illness.

Some of the state proposals specify certain conditions, such as biologically based mental illnesses, while others would require all mental health conditions be treated the same as physical illnesses. We do not support government-mandated benefits; however, we do support appropriate care and treatment for mental illness. They are touted as preventing racially discriminatory practices in the selection of providers. The concerns of minority providers have grown as more health plans have entered the Medicare market—and as states have turned to managed care systems for their Medicaid programs—because health plans, responding to pressures from employers and consumers, contract with board-certified providers only.

Historically, minority providers have not applied for board certification. Cigna provider networks reflect the demographics of the provider community and the member population. In certain instances, this practice is considered to be experimental.

We do not prohibit off-label use of approved medications, but use of certain drugs does require preauthorization. Requests for coverage for off-label drug use are reviewed on a case-by-case basis.

PHOs seek exemptions from federal antitrust standards, as well as state and federal solvency requirements and other consumer protection standards imposed on HMOs and insurers. As part of the Balanced Budget Act, PHOs were successful in their attempt to get special status to participate in the Medicare Risk program allowing them to meet less rigorous financial standards. We believe that there should be a level playing field for all managed care players.

All competitors should have to meet the same regulatory requirements. Several anti-gag clause provisions are currently pending before Congress. Consumer education and preventive care are the most significant tools a managed care company has to keep health care affordable and provide access to quality care.

Quality health care is possible only when there is an open, unencumbered dialogue between physicians and their patients. We believe that our members should be fully informed. Our members cannot make sound, sensible decisions if they have been given inadequate or incomplete information.

In addition, physicians are free to discuss Cigna physician reimbursement with their patients e. Consequently, we have never imposed restrictions on health care-related communication between physician and patient. Managed care emphasizes the importance of the primary care physician who is specially trained for this role. Most specialists do not meet the training requirements to be primary care providers. The primary care physician leads the team helping the member to manage their multiple health conditions and treatments—often, this includes assuring proper access to specialty care and making sure that all of the specialists are keeping one another informed.

This decision would be made as a part of our case management process, which is an integral part of all Cigna health plans. Utilization Management Utilization management is one of the tools Cigna uses to help make sure our customers get coverage for quality care. It involves having health care professionals review tests and procedures that your provider orders to determine if your Cigna plan will cover the cost. They also make sure the treatment is medically necessary.

Medical professionals make coverage decisions consistent with the terms of your health plan. These professionals use established guidelines to help them make decisions about whether a procedure is medically necessary based upon the specific facts of each coverage request. Cigna medical professionals do not receive any financial or other reward or incentive from any Cigna company, or otherwise, for approving or denying individual requests for coverage. Utilization management includes prior authorization for certain elective surgeries, procedures, and tests.

Prior authorization is a request for coverage of a health care service or treatment that requires clinical review. Prior authorization not only helps protect customers from undergoing unnecessary procedures, but also promotes use of participating providers that meet Cigna standards for quality.

Another component of utilization management is concurrent review. It includes discharge planning, including assisting with arrangements for home health care services, when medically necessary. Cigna considers several sources of information to make consistent and accurate coverage determinations.

Utilization Management-Dental Utilization management UM is a program we use to make sure our customers get coverage for appropriate care. It involves having a dentist review procedures that your dentist submits.

Our team of dental professionals reviews these procedures to determine if your Cigna plan will cover the cost. This helps save you money so you're not paying for unnecessary care. How does the Cigna dental team decide what my plan covers and whether a treatment is medically necessary?

Dental professionals make coverage decisions using the terms of your dental plan. They'll look to see what benefits your plan covers. They'll also look at what it doesn't cover. These professionals follow guidelines to help them decide if a procedure is medically necessary. The guidelines are not a substitute for your dentist's judgment.

This means that your dentist can discuss your situation with our team if there's a difference of opinion about whether a procedure is medically necessary.

Please note that the use of clinical guidelines is not new. The dental community has traditionally used these guidelines as part of the utilization management decision-making process.

Individuals involved in utilization management and the review process include Cigna employees in the Clinical, Quality Management, and Claim departments. These employees do not get any financial reward or incentive from any Cigna company, or otherwise, for approving or denying coverage requests. If you have a Cigna Dental Care plan, you must choose a primary care dentist also known as your network general dentist.

This is the dentist you'll use for all of your basic care. If you need specialty care, your primary care dentist will give you a referral. For your plan to cover the cost of your care, all of the dentists you use must participate in the Cigna Dental Care network. Your plan doesn't require any pre-authorizations. If you need a lot of specialty dental work done, you may be concerned about whether your plan will cover it.

Cigna will review the treatment plan if you ask us. It's possible that we may deny a claim when we review it, if it doesn't meet your plan terms. If you have a DPPO plan, you can choose to use in-network dentists or go out of network. You'll typically get better benefits if you stay in-network. The terms of your plan will tell you what benefits you are eligible for.

You do not need to get pre-authorization for dental procedures. If you need a lot of dental work done, and are concerned about whether your plan will cover it, Cigna will review the treatment plan if you ask us. All rights reserved. All insurance policies and group benefit plans contain exclusions and limitations. For availability, costs and complete details of coverage, contact a licensed agent or Cigna sales representative.

This website is not intended for residents of New Mexico. Selecting these links will take you away from Cigna. Cigna may not control the content or links of non-Cigna websites. Evaluation for hyperprolactinemia can be considered. The PEM detectors are integrated into a conventional mammography system, allowing acquisition of the emission images immediately after the mammogram. BR Digital Breast Tomosynthesis Cigna considers digital breast tomosynthesis DBT , also called 3D mammography, a medically appropriate imaging option in the screening of breast cancer.

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