Cigna’s announced policy to automatically downcode physician claims for complex visits (Evaluation and Management codes 4 and 5) has faced significant backlash from doctors who argue it threatens fair reimbursement and autonomy. While the policy was initially slated to start October 1, 2025, Cigna has since paused it, citing advocacy from medical organizations. The core of the policy change involved the insurer unilaterally downgrading claims it deemed not to meet its documentation standards, which would place the burden of appeal on physicians. [1, 2, 3, 4, 5]
Policy details and impact
- What it is: A policy that would automatically reduce the reimbursement for certain higher-level E/M codes if Cigna reviewers determine the documentation does not support the complexity of the visit. [1, 5]
- Affected codes: The policy primarily targets Level 4 and 5 codes for new and established patients (e.g., 99204-99205, 99214-99215) and consultations (99244-99245). [1, 5, 6]
- Physician burden: Doctors would have to appeal the decision by submitting additional documentation to prove their initial coding was correct, a process seen as an administrative hurdle. [1]
- Doctor concerns: Physicians are concerned this policy will lead to underpayment, increase administrative work, and contribute to burnout, potentially causing many to stop seeing Cigna patients. [1, 2]
Policy status
- Initial effective date: October 1, 2025. [1]
- Pause announced: Cigna temporarily paused the policy due to pressure and advocacy from medical groups like the American Academy of Sleep Medicine and the California Medical Association. [3, 4]
- Reason for pause: The pause followed inquiries into the policy’s legality and negotiations with medical organizations. [3, 4]
- Next steps: Cigna indicated it would analyze the policy, which now reportedly focuses only on providers who consistently code at the highest levels. [1, 7]