Breaking: Cigna’s New Automatic Downcoding Policy—What Providers Need to Know and How to Fight Back

DNP Consulting
Aug 26
3 min read

Updated: Aug 27

Cigna’s New Automatic Downcoding Policy

Cigna has announced a controversial new reimbursement rule that could dramatically impact physicians and advanced practice providers across the country. Beginning October 1, 2025, Cigna will implement a policy called “Evaluation & Management Coding Accuracy (R49).”

This policy applies to higher-level office visits—99204, 99205, 99214, 99215, 99244, and 99245—and allows Cigna to automatically reduce (“downcode”) claims by one level if their algorithm determines documentation does not support the billed code.

Providers will then have to appeal every single downcoded visit by submitting full documentation in order to get paid correctly (Cigna Provider Newsroom).

Why This Matters

Critics, including the California Medical Association and members of Congress, are sounding the alarm:

It shifts the burden of proof onto providers, who will be forced into an endless cycle of appeals.
It may violate state laws that require health plans to use nationally recognized coding standards and to disclose payment methodologies.
It sets a dangerous precedent for other payers to follow suit.

In short, this is more than an administrative hassle—it could represent a systemic cut to physician revenue streams and further strain already overwhelmed practices (Inside Health Policy coverage).

What You Can Do Now

1. Audit and Track Your Claims

Flag the six impacted codes and monitor every Explanation of Benefits (EOB) from Cigna. Document how often they’re downgraded, the reason given, and the appeal outcome. This evidence will be essential for regulators and lawmakers.

2. Appeal Every Downcode

Cigna is directing providers to fax appeals with full records to 833-392-2092 (Texas Medical Association Alert). Build standardized appeal packets that include:

Full visit note with MDM elements or exact time documented
Problem list, medications, labs/studies reviewed
Risk factors clearly stated

3. Join With State and Specialty Societies

In 2023, organized medicine forced Cigna to delay a burdensome “modifier 25” policy. The same coalition power is needed now. Connect with your state medical society and specialty groups to add your voice (AMA News: Cigna policy delay).

4. File Complaints With Regulators

For fully insured plans, cite state rules requiring plans to disclose payment rules and avoid “unjust payment patterns.” Submitting EOB evidence strengthens the case.

5. Engage Employers

Remember, most Cigna members are in self-funded employer plans. HR and benefits leaders can pressure Cigna to suspend the policy for their plan if they see the cost of delayed payments and appeals.

6. Protect Your Patients

Train front desk and billing staff to explain neutrally that insurer policies may cause payment delays, but you are actively working to resolve them. This keeps trust intact while you fight the policy.

Day-to-Day Documentation Defense

Use clear headers for MDM: Problems, Data, Risk.
Always document time for time-based billing.
Make E/M justification obvious in the first few lines of your note.

The cleaner your notes, the easier your appeals—and the stronger your case to regulators.

Final Word: Cigna’s New Automatic Downcoding Policy

This is not the first time Cigna has tested aggressive payment tactics. And it won’t be the last. But if providers push back collectively—through data, appeals, and advocacy—policies like R49 can be delayed or overturned, just as happened with the 2023 modifier 25 rule.

Now is the time to prepare, organize, and make your voice heard.

DNP Consulting: Free Download: R49 Response Kit

To help you take immediate action, we’ve created a practical toolkit you can use in your practice:

✅ Appeal Template Letter – Pre-drafted language you can customize and fax to Cigna when your claim is downcoded.

✅ Claims Tracking Spreadsheet (Excel) – Log CPT codes, initial level, downcoded level, appeal date, outcome, and payment timeline.

✅ Regulator Complaint Boilerplate – A customizable template for filing complaints with your state Department of Insurance.

Download the R49 Response Kit here