TL;DR: Cigna Healthcare modified policy UM-47 (um47-lack-of-information-retrospective-review), effective February 18, 2026, changing how the payer handles retrospective claim reviews when clinical information is missing. Here's what billing teams need to do.
When Cigna pends a post-service claim because it doesn't have enough clinical documentation to make a coverage decision, this policy is the rulebook. UM-47 establishes the process Cigna follows when it can't complete a retrospective review due to a lack of information—and the February 18, 2026 update modifies that process. This policy does not list specific CPT, HCPCS, or ICD-10 codes. It applies broadly across claim types where retrospective review is triggered.
Quick-Reference Table
| Field | Detail |
|---|---|
| Payer | Cigna Healthcare |
| Policy | Lack of Information (LOI) Retrospective Review |
| Policy Code | um47-lack-of-information-retrospective-review |
| Change Type | Modified |
| Effective Date | 2026-02-18 |
| Impact Level | High |
| Specialties Affected | All specialties subject to retrospective (post-service) utilization review |
| Key Action | Audit your clinical documentation workflows and response processes for Cigna retrospective review requests before February 18, 2026 |
Cigna Retrospective Review Coverage Policy and Medical Necessity Requirements 2026
The core of UM-47 is this: when Cigna initiates a retrospective (post-service) utilization review and doesn't have the clinical information it needs to make a medical necessity determination, it will "pend" that decision. The policy exists to make that pend process consistent across Cigna's systems.
That word—pend—is doing a lot of work here. A pended retrospective claim isn't denied yet. But it's not approved either. It sits in limbo until Cigna gets the documentation it needs to complete its review.
This matters because pended claims have timelines. If your team doesn't respond to a Cigna request for clinical information within those windows, a pend turns into a denial. At that point, you're fighting a claim denial instead of preventing one.
The Cigna retrospective review coverage policy under UM-47 applies broadly. It covers any post-service claim where Cigna's utilization management team determines it lacks the clinical documentation reasonably necessary to make a coverage or medical necessity decision. This isn't a specialty-specific policy—it touches every service line where Cigna conducts retrospective review.
The updated Cigna coverage policy doesn't publish specific clinical criteria for what counts as "sufficient" documentation. That's actually the gap you need to manage. Your team has to anticipate what Cigna will ask for before the request arrives—not scramble after the fact.
Prior authorization was handled at the front end. Retrospective review is the back-end check. UM-47 governs what happens when that back-end check stalls because Cigna can't evaluate the claim without more information. If your prior authorization records, operative notes, progress notes, or discharge summaries aren't attached to the claim or readily retrievable, UM-47 is the policy that determines how Cigna handles the resulting gap.
Coverage Indications at a Glance
This policy does not define covered or non-covered indications by procedure or diagnosis. It governs a process—how Cigna pends retrospective review decisions when clinical information is missing—not a clinical coverage determination for a specific service.
| Situation | Status Under UM-47 | Notes |
|---|---|---|
| Retrospective claim with complete clinical documentation | Standard review proceeds | No pend triggered under UM-47 |
| Retrospective claim with missing clinical information | Pended pending receipt of documentation | UM-47 governs the pend process and timelines |
| No response to Cigna's documentation request | Likely claim denial | Failure to supply information within Cigna's required window is the core risk |
| Prior authorization records unavailable post-service | High pend risk | Ensure PA records are stored and retrievable for retrospective requests |
Cigna Retrospective Review Billing Guidelines and Action Items 2026
The February 18, 2026 effective date is your deadline to have these workflows in place. Don't wait until a pend notice lands in your inbox.
| # | Action Item |
|---|---|
| 1 | Map every Cigna retrospective review request to a response owner. Someone on your billing team needs to own Cigna LOI requests end to end. If a pend notice sits unread for five days, you've already burned part of your response window. |
| 2 | Build a documentation retrieval protocol before the effective date. When Cigna pends a claim for lack of information, you need clinical records fast. Work with your clinical staff now to define how records get pulled and who approves the submission. This is not a workflow to build in response to a pend—it needs to exist before one arrives. |
| 3 | Audit your retrospective review billing guidelines against UM-47. Pull your internal Cigna billing guidelines and compare them to the updated policy language. If your internal process doesn't account for the pend-due-to-LOI scenario, update it before February 18, 2026. |
| 4 | Track pend-to-denial conversion rates on Cigna claims. If your practice is seeing retrospective claims move from pend to denial without your team responding, that's a documentation retrieval failure. Measure it. You can't fix what you don't track. |
| 5 | Verify reimbursement timelines for pended claims. A pend stops the reimbursement clock. If claims sit pended for weeks because your team isn't responding to LOI requests, your accounts receivable will show it. Set internal alerts for any Cigna retrospective claim that goes more than seven days without a documentation response. |
| 6 | Flag high-risk service lines for extra documentation prep. Services with complex medical necessity criteria—inpatient admissions, surgical procedures, high-cost specialty drugs—are the most likely candidates for retrospective review. These are the claims where an LOI request is most likely, and where reimbursement exposure is highest. |
| 7 | Loop in your compliance officer if your process is unclear. UM-47 is a process policy, not a clinical criteria policy. If your team isn't sure how your documentation workflows align with Cigna's pend timelines and response requirements, get your compliance officer involved before the effective date of February 18, 2026—not after your first pend-to-denial conversion. |
| Previous Version | Current Version |
|---|---|
| Coverage is considered experimental and investigational for all indications | Coverage is considered medically necessary when specific criteria are met |
| Prior authorization is not required | Prior authorization is required for initial treatment |
| Documentation must include clinical history | Documentation must include clinical history |
| Re-review every 24 months | Re-review every 12 months with updated clinical documentation |
CPT, HCPCS, and ICD-10 Codes for LOI Retrospective Review Under um47-lack-of-information-retrospective-review
This policy does not list specific CPT, HCPCS, or ICD-10 codes. UM-47 is a utilization management process policy. It applies across all claim types subject to Cigna retrospective review, not to a defined set of procedure or diagnosis codes.
There are no code-level tables to publish for this policy because Cigna has not tied UM-47 to specific codes. Every service line your practice bills to Cigna is potentially subject to retrospective review—and therefore potentially subject to a pend under UM-47.
If Cigna issues a supplemental notice that ties specific codes to this policy, PayerPolicy will publish an update.
The Real Issue With UM-47
Here's the honest take: a payer policy that formalizes how it pends claims for missing information isn't inherently provider-friendly. It creates a documented process that protects Cigna's ability to delay coverage decisions—and places the burden squarely on your team to respond fast with complete clinical records.
The modification on February 18, 2026 signals that Cigna is tightening consistency in how it handles these situations. That's a signal for your billing team, too. Ad hoc responses to LOI requests won't cut it. You need a repeatable process that gets the right clinical documentation to Cigna within their required window—every time.
The practices that handle this well aren't the ones with the best medical records systems. They're the ones where billing and clinical staff communicate fast, where documentation is organized and retrievable, and where someone owns the response process from pend notice to submission. That's a workflow problem, not a technology problem.
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