The California Medical Association (CMA) is urging Cigna to rescind a recently announced automatic downcoding policy. The policy, which applies to Cigna’s commercial plans, would allow the insurer to automatically downcode high-level Evaluation and Management (E/M) services whenever it determines the encounter criteria on a claim does not support the level billed. 

Physicians who dispute these downcoding decisions would be forced to file an appeal and submit supporting medical records via fax, creating substantial costs for both physicians and the plan itself. 

In a letter to Cigna, CMA warned the policy may violate state law, creates unnecessary administrative burdens, and fails to align with nationally recognized standards. 

“Cigna’s policy undermines the integrity of the E/M coding framework and appears inconsistent with AMA and CMS standards — as well as California law that requires health plans to follow nationally recognized guidelines,” CMA wrote. 

The new policy, known as Evaluation and Management Coding Accuracy (R49) – which takes effect October 1, 2025 – affects Evaluation & Management (E/M) codes 99204-99205, 99214-99215, and 99244-99245. 

New policy appears to violate state law 

Despite multiple requests, Cigna has not yet provided additional details, including the specific criteria it will use to adjudicate level 4 and 5 E/M claims. CMA believes this lack of disclosure violates California law, which requires health plans to disclose “detailed payment policies and rules and non-standard coding methodologies used to adjudicate claims.” 

Additionally, since it appears Cigna will be performing level 4 and 5 E/M reviews at the outset of receiving a claim, CMA presumes that the assessment is primarily based on a patient’s diagnosis billed on the submitted claim. While Cigna asserts that its policy is consistent with the American Medical Association’s (AMA) CPT coding guidelines, its use of claim-level criteria to determine the appropriateness of E/M levels, without considering the documented total time or medical decision-making, appears inconsistent with both AMA and CMS guidelines. 

“This policy will unnecessarily increase administrative burden and costs for both physicians and Cigna, while functioning less as a tool to promote accuracy and more as a barrier to appropriate reimbursement,” CMA cautioned. 

CMA believes a more constructive approach – such as leveraging provider education on appropriate coding practices or focusing on education of outliers, rather than broadly penalizing physicians who are billing appropriately in accordance with AMA guidance – would be more effective and sustainable in the longer term. 

CMA will continue to press Cigna to rescind the policy and protect physicians from arbitrary and unlawful downcoding practices. 

Practices with concerns regarding this policy update are encouraged to contact Cigna Customer Service at (800) 88-Cigna (882-4462). More information regarding this change can be found on the Cigna for Health Care Professionals portal.