Cigna's downcode policy excludes behavioral health providers
Ask Cigna which policy lowered your 99214. If the answer is R49, quote the policy's own exclusion back with the full record of the encounter.
Co-founder, JotPsych
Your Cigna explanation of payment shows a 99214 paid as a 99213. Don't accept the lower payment yet.
Cigna's downcode policy, R49, lets Cigna pay a level 4 or 5 evaluation and management (E/M) visit one level lower: codes 99204, 99205, 99214, 99215, 99244, and 99245. R49 excludes claims submitted by behavioral health providers, and Cigna's November 2025 notice limits the policy to providers who code higher than their peers.
This claim was submitted by a behavioral health provider.
Cigna reimbursement policy R49 states: "Claims submitted by behavioral health providers are excluded from the E/M level adjustment."
The full record of the encounter is attached and supports the level billed, 99214.
Please reprocess the claim at 99214.
The paragraph to send when Cigna lowered a 99214 under R49, with the full record attached. The second line quotes R49 word for word, so a reviewer can check the quote against the policy.
Three steps to question the payment
- Ask which policy lowered your claim. Call Cigna or check your claim online. The exclusion applies to your claim only if the answer is R49. R49 doesn't define "behavioral health providers," so also ask whether Cigna counts your practice as one.
- Read R49's current version. Cigna reviews R49 every year. Check the current text before you quote it.
- Send your reconsideration request with the full record. Cigna asks for your patient's full record of the encounter, sent online as a reconsideration or by secure fax. Under R49, Cigna pays the level you billed when your medical records "substantiate the complexity" of that level, by medical decision making or by time.
Claims submitted by behavioral health providers are excluded from the E/M level adjustment.
However, claims for behavioral services are not otherwise excluded from E/M level adjustment.
The two sentences on behavioral health in Cigna's policy R49, quoted from the policy. The exclusion depends on who submits the claim, so a behavioral health provider's lowered claim is one to question.
Two more lines in Cigna's November 2025 notice
The notice says R49 "does not affect Evernorth Behavioral Health claims." Evernorth Behavioral Health is a Cigna Group company. Ask Cigna whether Evernorth processed your claim.
The notice also offers a bypass from R49. If you have five or more adjusted claims and believe your coding follows the American Medical Association's guidelines, email EMCodingAccuracy@
Find your other lowered Cigna claims
Run one report: each CPT code you billed, beside the code Cigna paid. Taya Gordon, who runs a health care consulting firm, gives practices this first step: "Run a report of mismatches between CPT billed and CPT reimbursed." Each 99214 that Cigna paid you as a 99213 shows up on the report.
Cigna asks for the full record. Export chart in JotPsych builds one file from the notes and documents you select, with a contents list.
See JotPsych- Taya Gordon, chief executive officer of Atlas & Perpetua Healthcare Consulting, “Strategic Revenue Cycle Workplan Design for High-Impact Payer Engagement,” workshop WS1, Medical Group Management Association (MGMA) 2026 Annual Conference, San Antonio, September 27, 2026.
- Cigna Healthcare, Evaluation and Management Coding and Accuracy, Reimbursement Policy R49, last updated September 30, 2025, annual review date October 1, 2026; read October 3, 2026.
- Cigna Healthcare, New reimbursement policy for professional evaluation and management services claims effective October 1, 2025, Provider Newsroom, November 18, 2025.
- Cigna Healthcare, Professional claims for evaluation and management services, Provider Newsroom, November 18, 2025.