Cigna has agreed to pause implementation of its new “Evaluation and Management Coding Accuracy” reimbursement policy pending review by the California Department of Managed Health Care (DMHC). The pause follows the California Medical Association’s (CMA) inquiry to state regulators about the policy’s legality, which prompted DMHC to engage with Cigna.

The policy, originally scheduled to take effect October 1, 2025, would allow Cigna to automatically downcode higher-level Evaluation and Management (E/M) services whenever the plan determines that documentation does not support the billed level. Physicians disputing these decisions would be required to file an appeal and submit medical records by fax – a process CMA has warned creates unnecessary administrative burdens and costs.

CMA has cautioned that the policy appears to violate state law, is inconsistent with nationally recognized coding standards, and functions as a barrier to appropriate reimbursement and patient care.

“In practice, these policies function less as tools to promote accuracy and more as barriers designed to disincentivize billing for higher level E/M services—even when clinically appropriate,” CMA wrote in a letter to Cigna. “This approach also introduces avoidable friction with physician practices into the process, erodes trust between providers and plans, and exacerbates the challenges of delivering high-quality care in a resource-constrained environment.”

The American Medical Association has likewise raised strong concerns, joining CMA in urging Cigna to rescind the policy.

CMA has requested clarification on which Cigna products are affected by the pause, and will continue to press for full withdrawal of the policy.

Next Steps for Physicians

While Cigna has agreed to a temporary pause, CMA encourages physicians and medical groups to continue voicing their concerns until the policy is formally withdrawn. When contacting Cigna, physicians should emphasize that:

• The policy lacks transparency and fails to disclose claims adjudication criteria.
• It conflicts with AMA and CMS E/M coding guidelines.
• It risks violating California’s claims payment and disclosure laws.
• It will increase administrative burdens and costs for both practices and the insurer.

Please contact Cigna Customer Service at (800) 88-Cigna (882-4462) or via the provider portal and request that the company rescind the R49 downcoding policy. CMA has also prepared talking points practices can use when communicating with Cigna on this issue.

CMA will continue to update members as the regulatory review progresses.