Cigna Coverage for Joint Pain Injections and Therapy

Understanding Cigna Coverage for Joint Pain

Cigna offers health insurance to millions of Americans through employer plans, marketplace options, and Medicare Advantage. If you have joint pain from osteoarthritis, Cigna covers several treatment options. However, getting approval requires knowing how their system works, especially their partnership with Evicore for prior authorization.

This guide explains what Cigna covers, how to get approval, and what to do if your claim is denied.

Cigna Plan Types

Cigna offers several plan types, and coverage can vary between them:

Employer-Sponsored Plans

Most Cigna members get coverage through their employer. These plans follow Cigna’s clinical policies but may have different:

• Deductibles and copays
• Prior authorization requirements
• Visit limits for physical therapy
• Preferred provider networks

Individual and Marketplace Plans

Plans purchased through the ACA marketplace or directly from Cigna follow standard clinical guidelines. Your metal tier (Bronze, Silver, Gold, Platinum) affects how much you pay out of pocket.

Cigna Medicare Advantage

If you have Cigna Medicare Advantage, your coverage follows Medicare guidelines with Cigna’s cost-sharing structure. Prior authorization requirements may differ from commercial plans.

Covered Treatments

Quick Coverage Summary

Hyaluronic Acid Injections

Cigna covers viscosupplementation (HA injections) for knee osteoarthritis when you meet medical necessity requirements. All FDA-approved HA products are generally covered, including single-injection and multi-injection formulas.

Requirements for coverage:

• Documented knee osteoarthritis diagnosis
• Imaging (X-ray or MRI) showing joint changes
• Failed conservative treatment for at least 3 months
• Prior authorization through Evicore

Cortisone Injections

Corticosteroid injections are covered without prior authorization in most cases. Cigna limits the number of injections per joint per year, typically 3-4 times.

Physical Therapy

Physical therapy is covered but usually has visit limits. Most Cigna plans allow 20-30 sessions per year. Some plans require a referral from your primary care doctor.

Treatments Not Covered

Cigna does not cover:

• PRP injections - Considered investigational
• Stem cell therapy - Considered experimental
• Prolotherapy - Limited evidence

Evicore Prior Authorization

What Is Evicore?

Evicore is a third-party company that handles prior authorization for Cigna. When your doctor requests approval for hyaluronic acid injections, the request goes to Evicore, not Cigna directly.

Evicore reviews your medical records against Cigna’s clinical guidelines. They decide whether your treatment is medically necessary.

How the Evicore Process Works

Documentation Evicore Requires

To approve your request, Evicore needs:

• X-ray or MRI report showing osteoarthritis
• Records of physical therapy or home exercises
• List of medications tried (NSAIDs, acetaminophen)
• Notes showing how pain affects your daily activities
• Previous injection history and response

Step Therapy Requirements

What Is Step Therapy?

Many Cigna plans require “step therapy.” This means you must try certain treatments first before Cigna will approve others. For joint injections, the typical steps are:

1. First: Conservative care (PT, NSAIDs, activity changes) for 3+ months
2. Second: Cortisone injection trial
3. Third: Hyaluronic acid injections if cortisone did not work

Why This Matters

If you skip directly to HA injections without trying cortisone first, Evicore may deny your request. Make sure your medical records document:

• What treatments you tried
• How long you tried them
• Why they did not work

In-Network Benefits

Why In-Network Matters

Using in-network providers saves you money. Here is how costs compare:

In-Network:

• Lower deductible
• Lower coinsurance (typically 20%)
• No balance billing
• Counts toward your out-of-pocket maximum

Out-of-Network:

• Higher or separate deductible
• Higher coinsurance (40-50%)
• Provider can bill you for amounts above Cigna’s allowed rate
• May not count toward out-of-pocket maximum

Finding In-Network Providers

Before scheduling treatment:

1. Log into myCigna.com and use “Find Care & Costs”
2. Call Cigna at 1-800-244-6224
3. Ask your provider: “Are you in-network with Cigna?”
4. Verify both the facility and the doctor are in-network

Understanding Your Costs

Typical Cost Components

Example Cost Calculation

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

• HA injection series: $900 (negotiated rate)
• You have met $800 of your deductible
• Your cost: $700 (remaining deductible) + $40 (20% of $200) = $740

After reaching your out-of-pocket maximum, Cigna pays 100% of covered services for the rest of the year.

Appealing a Denial

If Evicore or Cigna denies your request, you have the right to appeal. Many denials are overturned with proper documentation.

Appeal Timeline

• Level 1 appeal: File within 180 days of denial
• Level 2 appeal: File within 60 days if Level 1 is denied
• External review: Available after internal appeals are exhausted

How to Strengthen Your Appeal

For detailed appeal strategies, see our insurance denial appeal guide.

Key Takeaways

1. Evicore handles prior authorization - Your request goes to Evicore, not Cigna directly
2. Step therapy may be required - Try conservative care and cortisone before HA injections
3. Use in-network providers - Saves hundreds to thousands of dollars
4. Get written approval first - Never schedule treatment before authorization is confirmed
5. Appeals are possible - Many denials are overturned with complete documentation

Related Resources

• Hyaluronic Acid Injections: Complete Guide
• How to Appeal an Insurance Denial
• Medicare Coverage for Joint Injections
• Prior Authorization for Joint Injections