PAYER APPEAL GUIDE · PA VENDOR

How to appeal a EviCore denial

EviCore (an Evernorth/Cigna company) is a benefit-management vendor that runs prior authorization for many health plans — Cigna and various commercial and Medicare Advantage plans — across radiology and advanced imaging, cardiology, radiation and medical oncology, musculoskeletal, sleep, lab, and post-acute care. When one of these services is denied for authorization, the decision was usually made by EviCore, not the health plan, so that's where the appeal starts.

The most common EviCore denials

  • Advanced imaging (MRI, CT, PET) denied as not meeting EviCore clinical criteria
  • Cardiology, radiation/medical oncology, MSK, and sleep studies denied against EviCore guidelines
  • Conservative-therapy or step requirements not documented as met
  • Authorization requested for the wrong CPT or site of service

How to appeal to EviCore

1
Start the reconsideration with EviCore — through its provider portal or by phone — since EviCore made the authorization decision
2
Request a clinical consultation / peer-to-peer with an EviCore physician; this is the fastest way to overturn an imaging or specialty-service denial
3
If EviCore upholds the denial, the formal appeal moves to the health plan under that plan's appeal process and timely window
4
Match the request to the exact code and site of service — a mismatch reads as no authorization

What wins with EviCore

  • Know EviCore's published clinical criteria for the study and document how the patient meets them — conservative therapy tried, symptoms, prior imaging
  • Use the peer-to-peer aggressively; a specialist-to-specialist conversation reverses many imaging denials on the spot
  • Get the auth for the precise CPT and place of service you'll bill, or the claim denies later even with an auth on file
  • Once EviCore upholds, don't stall — the plan-level appeal has its own separate deadline

Common questions

How do I appeal a EviCore denial?

EviCore (an Evernorth/Cigna company) is a benefit-management vendor that runs prior authorization for many health plans — Cigna and various commercial and Medicare Advantage plans — across radiology and advanced imaging, cardiology, radiation and medical oncology, musculoskeletal, sleep, lab, and post-acute care. When one of these services is denied for authorization, the decision was usually made by EviCore, not the health plan, so that's where the appeal starts. The path: start the reconsideration with EviCore — through its provider portal or by phone — since EviCore made the authorization decision; request a clinical consultation / peer-to-peer with an EviCore physician; this is the fastest way to overturn an imaging or specialty-service denial; if EviCore upholds the denial, the formal appeal moves to the health plan under that plan's appeal process and timely window; match the request to the exact code and site of service — a mismatch reads as no authorization.

What are the most common EviCore denials?

Advanced imaging (MRI, CT, PET) denied as not meeting EviCore clinical criteria; Cardiology, radiation/medical oncology, MSK, and sleep studies denied against EviCore guidelines; Conservative-therapy or step requirements not documented as met; Authorization requested for the wrong CPT or site of service.

How does Volari handle EviCore denials?

Volari identifies your written-off EviCore denials, builds each appeal with the payer-specific argument and documentation, files it through EviCore's process, and follows it to payment. You pay 25% only on what's recovered.

Where Volari fits: Volari identifies which denials are EviCore-managed, opens the reconsideration and peer-to-peer with EviCore's criteria in hand, and escalates to the health plan's appeal if EviCore upholds.

Other payers
UnitedHealthcare →UnitedHealthcare E/M Downcoding →UnitedHealthcare Prior Authorization →Aetna →Aetna Medical Necessity (Clinical Policy Bulletins) →Cigna →Cigna Modifier 25 Policy →Blue Cross Blue Shield →Anthem Blue Cross →Humana →Humana Medicare Advantage Denials →Carelon (formerly AIM Specialty Health) →Medicare Part B →UMR →Meritain Health →Oscar Health →HCSC (BCBS of IL, TX, OK, NM, MT) →Ambetter (Centene) →Anthem / Elevance E/M Downcoding →Aetna Claim-Edit & Downcoding Policies →

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