On August 23, 2024, The Cigna Group and Cigna Health and Life Insurance Company (“Cigna”) filed a motion to dismiss a lawsuit alleging the denial of coverage resulting from its use of an automated system. More specifically, the lawsuit, filed in the United States District Court for the Eastern District of California, asserts that Cigna was able to evade the use of physician review for coverage determinations through the use of its Procedure-to-Diagnosis (PxDx) algorithm.
Cigna, a major medical insurance company, asserted in its motion that the use of the PxDx system was proper, as its function was to identify non-covered claims. It stated that “rather than being some unlawful scheme to fill Cigna’s pockets, PxDx checks whether certain specific treatments that providers order are actually covered by the member’s benefit plan.”
This assertion responds to allegations in the plaintiffs’ Complaint that the PxDx system “enables its doctors to automatically deny payments in batches of hundreds or thousands at a time for treatments that do not match certain pre-set criteria, thereby evading the legally-required individual physician review process.”
The Complaint alleges the scope of this issue is significant, citing as an example that over a period of two months in 2022, “Cigna doctors denied over 300,000 requests for payments using this method, spending an average of just 1.2 seconds ‘reviewing’ each request.”
Regarding PxDx-related arguments, Cigna also contended that several plaintiffs, despite alleging their claims were denied using the PxDx system, failed to identify any plan terms demonstrating that such denials were contrary to the plan’s provisions. Furthermore, Cigna argued that these plaintiffs also failed to show any plan terms that would prohibit Cigna from using a claims review process like PxDx. Separately, Cigna asserted that the claims of three plaintiffs were not actually denied through the use of the PxDx system.
Categories: AI
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