Cigna Coverage for Joint Pain Treatments: Complete 2025 Guide

Understanding Cigna Coverage for Joint Injections

Cigna Healthcare covers many joint pain treatments, but understanding the requirements, costs, and authorization process can help you avoid unexpected bills and treatment delays. This guide explains what’s covered, what you’ll pay, and how to navigate Cigna’s approval process.

Quick Coverage Summary

Hyaluronic Acid Injection Coverage

What Cigna Typically Covers

Most Cigna plans cover viscosupplementation (HA injections) for knee osteoarthritis when medical necessity criteria are met. However, prior authorization is almost always required.

Medical Necessity Requirements

To qualify for HA injection coverage under Cigna:

1. Documented osteoarthritis diagnosis

   • X-ray or MRI showing joint degeneration
   • Clinical examination findings in medical records
   • Clear documentation of symptoms and functional limitations

2. Conservative treatment failure

   • At least 3 months of documented conservative therapy
   • Must typically include:
     • Physical therapy or home exercise program
     • Over-the-counter or prescription NSAIDs
     • Activity modifications
     • Weight management (if applicable)

3. Step therapy requirements

   • Many Cigna plans require trial of cortisone injections first
   • If cortisone provides inadequate or short-term relief, HA may be approved
   • Document the outcome and duration of any cortisone treatments

4. Treatment frequency limits

   • Typically one injection series per joint every 6 months
   • Some plans allow retreatment only if prior series provided 3+ months relief

Prior Authorization Process

Prior authorization (PA) is the most critical step for HA injection coverage:

Step 1: Verification

• Your provider’s office initiates the PA request
• Cigna reviews within 3-5 business days (urgent) or 15 days (routine)
• Extension possible if additional information needed

Step 2: Documentation Submission

• Medical records showing diagnosis and imaging
• Conservative treatment history with dates and outcomes
• Clinical notes explaining why HA is appropriate
• Previous injection history and response

Step 3: Decision

• Approval: Valid for specific timeframe (usually 30-90 days)
• Denial: Must include specific reason and appeal rights
• Partial approval: May approve with conditions or limitations

What You’ll Pay: Understanding Costs

In-Network Providers

With in-network providers, your costs typically include:

1. Deductible

• Must be met before coinsurance applies
• Ranges from $500-$5,000+ depending on plan
• Family vs. individual deductibles may apply

2. Coinsurance

• You pay a percentage after deductible is met
• Common split: 80/20 (Cigna pays 80%, you pay 20%)
• Or: 70/30, 90/10 depending on plan

3. Copay vs. Coinsurance

• Some plans use fixed copays instead of coinsurance
• Specialist copay: $40-$75 typical
• Outpatient procedure copay: $100-$300 typical

Example Cost Calculation (In-Network):

If your plan has a $1,500 deductible and 80/20 coinsurance:

• HA injection series negotiated rate: $800
• You’ve met $1,000 of your deductible so far
• You pay: $500 (remaining deductible) + $60 (20% of remaining $300) = $560

Out-of-Network Providers

Out-of-network costs are significantly higher:

• Separate, higher deductible (often $3,000-$6,000+)
• Higher coinsurance (you pay 40-50% instead of 20%)
• Balance billing - provider can bill you for amount above Cigna’s allowed amount
• Prior authorization may not be available for out-of-network care

Example Cost Calculation (Out-of-Network):

Same injection, out-of-network provider charges $1,200:

• Cigna allows $800 (reasonable and customary)
• Out-of-network deductible: $3,000 (not yet met)
• You pay: $800 (toward deductible) + $400 (balance bill) = $1,200 full cost

Out-of-Pocket Maximums

Every Cigna plan has an annual out-of-pocket (OOP) maximum:

• Individual OOP max: $3,000-$9,100 (ACA marketplace plans)
• Family OOP max: $6,000-$18,200
• Once you reach this amount, Cigna pays 100% of covered services

Cortisone Injections Under Cigna

Corticosteroid injections are typically easier to get approved:

Coverage Requirements

• Medical necessity documentation
• In-network provider recommended for lower costs
• Prior authorization usually not required

Limitations

• Frequency limits: typically 3-4 injections per joint per year
• Repeated cortisone may require medical necessity justification
• Research shows potential cartilage concerns with repeated use

When Cigna May Prefer Cortisone

Many Cigna plans have “step therapy” requirements:

• Try cortisone first (lower cost)
• If ineffective or short-term relief only, HA may be approved
• Document cortisone outcomes for HA authorization

Physical Therapy Coverage

Physical therapy for joint pain is generally covered but with limitations:

Authorization Requirements

• Prior authorization often required for outpatient PT
• Physician referral or prescription needed
• Must use in-network facility

Session Limits

• Typical limit: 20-30 visits per calendar year
• May be combined limit across all PT conditions
• Extensions possible with medical necessity documentation

Costs

• Copay per session: $20-$50 typical
• Or coinsurance: 20% after deductible
• May count toward deductible and OOP max

What Cigna Does NOT Cover

PRP (Platelet-Rich Plasma)

Cigna considers PRP for osteoarthritis experimental/investigational:

• Not covered under any standard plan
• Appeals rarely successful
• Costs: $500-$1,500+ per treatment (100% out-of-pocket)

Stem Cell Injections

Stem cell treatments for joint pain are not covered:

• Lack sufficient evidence for Cigna approval
• Often marketed aggressively despite limited proof
• Costs: $3,000-$10,000+ per treatment

Regenerative Medicine

Most “regenerative” therapies are excluded:

• Amniotic fluid injections
• Exosome therapy
• Prolotherapy (in most cases)

How to Ensure Your Treatment Is Approved

Before You Schedule

1. Verify your benefits

   • Call Cigna: 1-800-Cigna24 (1-800-244-6224)
   • Log in to myCigna.com
   • Ask: “Is viscosupplementation covered? Is prior authorization required?”

2. Confirm provider network status

   • Use Cigna’s online provider directory
   • Call provider’s office: “Do you accept Cigna? Are you in-network?”
   • Verify both facility and physician are in-network

3. Document conservative treatments

   • Keep records of PT sessions, dates, outcomes
   • List all medications tried with dates and effectiveness
   • Note any home exercise programs or activity modifications

4. Get imaging

   • X-rays or MRI showing osteoarthritis
   • Ensure reports are in your medical records

During Authorization

5. Work with your provider’s office

   • They should handle PA submission
   • Provide complete treatment history
   • Follow up on PA status after 5-7 business days

6. Get written approval

   • Don’t schedule until you receive PA approval number
   • Verify approval covers the specific treatment and provider
   • Check expiration date of authorization

After Treatment

7. Verify billing
   • Review EOB (Explanation of Benefits) from Cigna
   • Check that prior authorization was applied
   • Confirm in-network rates were used

Common Denial Reasons and How to Avoid Them

Documentation Issues

Problem: Insufficient evidence of conservative treatment failure

Solution: Provide detailed records with:

• Dates of PT sessions or home exercise program
• List of medications with dosages, dates, and outcomes
• Functional limitations and how they affect daily life

Problem: Missing or inadequate imaging

Solution: Ensure X-rays or MRI clearly document osteoarthritis and are in your medical records before PA submission

Process Issues

Problem: Prior authorization not obtained

Solution: Never schedule injection until you have written PA approval with authorization number

Problem: Out-of-network provider

Solution: Verify network status before treatment. If you must use out-of-network provider, obtain gap exception approval in advance

Timing Issues

Problem: Treatment too soon after previous injection series

Solution: Most plans require 6 months between series. If retreatment is needed sooner, provide detailed medical necessity justification

Problem: Authorization expired

Solution: Check PA expiration date. If treatment is delayed, request extension or new authorization

Appealing a Denial

If your HA injection claim is denied, you have appeal rights:

Level 1: Internal Appeal

Timeline: File within 180 days of denial date

Process:

1. Request written denial letter with specific reason
2. Gather supporting documentation:
   • Complete medical records
   • Conservative treatment history
   • Imaging reports
   • Peer-reviewed studies supporting HA efficacy
   • Letter from your provider explaining medical necessity
3. Submit appeal through myCigna.com or by mail
4. Cigna reviews within 30 days (60 days if additional info needed)

Level 2: Second Internal Appeal

If Level 1 is denied:

• File within 60 days of Level 1 denial
• Include any new evidence or documentation
• May request expedited review if urgent medical need

External Review

If internal appeals are exhausted:

• Request independent medical review
• File through your state insurance department
• Independent physician reviews your case
• Decision is binding on Cigna

Questions to Ask Before Treatment

Ask Cigna (1-800-244-6224):

1. “Does my plan cover viscosupplementation for knee osteoarthritis?”
2. “Is prior authorization required? What is the process?”
3. “What is my deductible and how much have I met?”
4. “What is my coinsurance or copay for this procedure?”
5. “Does my plan have step therapy requirements?”
6. “What is my out-of-pocket maximum and how much have I reached?”

Ask Your Provider’s Office:

1. “Are you in-network with Cigna?”
2. “Will you handle the prior authorization?”
3. “What are typical costs for patients with my plan?”
4. “Do you have documentation of my conservative treatment history?”
5. “What diagnosis and procedure codes will you use?”

Red Flags and Fraud Prevention

Be cautious of providers who:

• Guarantee coverage without checking your specific plan
• Ask you to pay full cost upfront and “reimburse you after insurance pays”
• Offer treatment without prior authorization when PA is required
• Bill for services not provided or inflate billing codes
• Market unproven treatments (PRP, stem cells) as “better than approved options”

Report Suspected Fraud

• Cigna Fraud Hotline: 1-800-Cigna24
• State insurance department
• National Insurance Crime Bureau: 1-800-835-6422

Cigna Medicare Advantage Plans

If you have Cigna Medicare Advantage (not Original Medicare):

Key Differences

• Coverage follows Medicare guidelines for medical necessity
• Cigna’s cost-sharing structure applies (may differ from Original Medicare)
• Prior authorization often required (unlike Original Medicare)
• Network restrictions apply
• Supplemental benefits may be included

What to Verify

1. “Does my Cigna Medicare Advantage plan cover HA injections?”
2. “Is prior authorization required?”
3. “What is my copay or coinsurance?”
4. “Are there network restrictions?”

Tips for Managing Costs

Use In-Network Providers

• Verify network status online at myCigna.com
• Call Cigna to confirm before scheduling
• Saves hundreds to thousands of dollars per treatment

Time Treatments Strategically

• If you’ve met your deductible late in the year, schedule treatment before plan year resets
• If close to out-of-pocket max, coordinate timing with other medical expenses

Ask About Payment Plans

Many providers offer:

• Interest-free payment plans
• Discounts for upfront payment
• Financial assistance programs for qualifying patients

Consider HSA or FSA

If your plan is HSA or FSA eligible:

• Use pre-tax dollars for out-of-pocket costs
• Deductibles, copays, and coinsurance are HSA/FSA eligible
• May include over-the-counter medications and supplies

Key Takeaways

1. Prior authorization is critical - Don’t schedule treatment without written approval
2. In-network providers save money - Verify network status before every appointment
3. Document conservative treatments - Thorough records are essential for approval
4. Step therapy may apply - Many plans require cortisone trial before HA approval
5. Appeals are possible - If denied, you have the right to appeal with supporting evidence
6. PRP and stem cells aren’t covered - Don’t expect insurance coverage for experimental treatments

Related Resources

• Medicare Coverage for Joint Injections - Compare Medicare vs. commercial insurance
• Prior Authorization for Joint Injections - Detailed guide to the PA process
• Understanding Out-of-Pocket Costs - Deductibles, coinsurance, and more
• Hyaluronic Acid Injections Guide
• HA vs. Cortisone Comparison
• How to Choose a Joint Pain Provider