“Not Medically Necessary”: Inside the Company Helping America’s Biggest Health Insurers Deny Coverage for Care

Reporting Highlights Dialing for Dollars: America’s largest insurers hire EviCore to make decisions on whether to pay for care for more than 100 million people.

“The Dial”: EviCore uses an algorithm that allows it to adjust the chances that company doctors will screen prior authorization requests, increasing the possibility of denials.

Lucrative Deals: Some EviCore contracts are based on how deeply the company can reduce spending on medical procedures. It tells insurers that it can provide a 3-to-1 return on investment. These highlights were written by the reporters and editors who worked on this story.Every day, patients across America crack open envelopes with bad news. Yet another health insurer has decided not to pay for a treatment that their doctor has recommended. Sometimes it’s a no for an MRI for a high school wrestler with a strained back. Sometimes for a cancer procedure that will help a grandmother with a throat tumor. Sometimes for a heart scan for a truck driver feeling short of breath.But the insurance companies don’t always make these decisions. Instead, they often outsource medical reviews to a largely hidden industry that makes money by turning down doctors’ requests for payments, known as prior authorizations. Call it the denials for dollars business.The biggest player is a company called EviCore by Evernorth, which is hired by major American insurance companies and provides coverage to 100 million consumers — about 1 in 3 insured people. It is owned by the insurance giant Cigna.A ProPublica and Capitol Forum investigation found that EviCore uses an algorithm backed by artificial intelligence, which some insiders call “the dial,” that it can adjust to lead to higher denials. Some contracts ensure the company makes more money the more it cuts health spending. And it issues medical guidelines that doctors have said delay and deny care for patients.EviCore and companies like it approve prior authorizations “based on the decision that is more profitable for them,” said Barbara McAneny, a former president of the American Medical Association and a practicing oncologist. “They love to deny things.”EviCore says it scrutinizes requests to make sure that procedures recommended by doctors are safe, necessary and cost-effective. “

We are improving the quality of health care, the safety of health care and, by very happy coincidence, we’re also decreasing a significant amount of unnecessary cost,” an EviCore medical officer explains in a video produced by the company.But EviCore’s cost-cutting is far from coincidental, according to the investigation.EviCore markets itself to insurance companies by promising a 3-to-1 return on investment — that is, for every $1 spent on EviCore, the insurer would pay out $3 less on medical care and other costs. EviCore salespeople have boasted of a 15% increase in denials, according to the investigation, which is based on internal documents, corporate data and dozens of interviews with former employees, doctors, industry experts, health care regulators and insurance executives. Almost everybody interviewed spoke on condition of anonymity because they continue to work in the industry.An analysis of the company’s own data shows that, since 2021, EviCore turned down prior authorization requests, in full or in part, almost 20% of the time in Arkansas, which requires the publication of denial rates. By comparison, the equivalent figure for federal Medicare Advantage plans was about 7% in 2022.They love to deny things.Barbara McAneny, former president of the American Medical AssociationEviCore has several ways to cut costs for insurers. Chief among them is the dial, the proprietary algorithm that’s the first stop in evaluating a prior authorization. Based on data entered by a doctor’s office, it can automatically approve a request.The algorithm cannot say no, however. If it finds problems, it sends the request for review to a team of in-house nurses and doctors who consult company medical guidelines. Only doctors can issue a final denial.This is where tweaking the dial comes in. EviCore can adjust the algorithm to increase the number of requests sent for review, according to five former employees. The more reviews, the higher the chance of denials.Here’s how it works, the former employees said: The algorithm reviews a request and gives it a score. For example, it may judge one request to have a 75% chance of approval, while another to have a 95% chance. If EviCore wants more denials, it can send on for review anything that scores lower than a 95%.

If it wants fewer, it can set the threshold for reviews at scores lower than 75%.“We could control that,” said one former EviCore executive involved in technology issues. “That’s the game we would play.”Over the years, medical groups have repeatedly complained that EviCore’s guidelines were outdated and rigid, resulting in inappropriate denials or delays in care. Frustration with the rules has led some doctors to refer to the company as EvilCore. There is even a parody account on X.The guidelines are also used as a tool to cut costs, the investigation found. Company executives “would say, ‘Keep a closer eye on the guidelines for reviews for a particular company because we’re not showing savings,’” said a former EviCore employee involved in the radiation oncology program.EviCore says that it develops its guidelines with the input of peer-reviewed medical studies and professional societies, and that they are routinely updated to stay current with the latest evidence-backed practices. It said its decisions are based solely on the guidelines and are not interpreted differently for different clients.EviCore is not alone in engaging in the denials-for-dollars business. The second-biggest player is Carelon Medical Benefits Management, a subsidiary of Elevance Health, the health insurer formerly known as Anthem. It has been accused in court of wrongfully denying legitimate requests for coverage. The company has denied all charges. Several smaller companies do the same kind of work.Simply put, EviCore uses the latest evidence-based medicine to ensure that patients receive the care they need and avoid the services they do not.A Cigna spokesperson in a statement provided on behalf of EviCoreThere is no question that prior authorizations play an important role in modern medicine. They serve to guard against doctors who recommend unnecessary and even potentially harmful treatments. They also protect insurers from fraudulent physicians who overbill for services.In a response to questions, a Cigna spokesperson provided a statement on behalf of EviCore. “Simply put, EviCore uses the latest evidence-based medicine to ensure that patients receive the care they need and avoid the services they do not,” it said.The statement acknowledged that EviCore used algorithms for some clinical programs, but “ONLY to accelerate approval of appropriate care and reduce the administrative burden on providers.

”The statement noted that doctors have the ability to appeal prior authorization denials, and that the company routinely monitors the outcomes “as part of our continuous quality improvement to ensure accurate and timely medical necessity decision-making.”Prior authorization reviews provided by EviCore save money for the entire health insurance system, the statement said. “The natural product of improved care quality and reduced waste is savings for our clients, lower out-of-pocket costs for patients, and fewer health care premium increases for Americans.”Turning the DialIn the fall of 2021, when the air grew crisp and the leaves reddened in central Ohio, Little John Cupp began feeling short of breath. He gasped while pushing a shopping cart. His feet and ankles swelled. He could only sleep while sitting up.An echocardiogram revealed that his heart was having trouble pumping blood. Cupp’s doctor suggested more testing, including the insertion of a catheter to examine whether his arteries were blocked.A few days after the doctor made the request, Cupp received a letter from his insurance company, UnitedHealthcare. The procedure, it said, was “not medically necessary.”

Little John Cupp provided support for his family, including buying a new four-bedroom trailer. Courtesy of Chris CuppOne sentence in 8-point type revealed that the insurer had outsourced the decision to EviCore.Cupp’s doctor put him on medications to reduce swelling and high blood pressure and tried a second time to win approval for a left heart catheter examination. EviCore turned it down again. He revealed his disappointment in shorthand in Cupp’s medical records: “ideally he needs LHC (denied twice by insurance).”Cupp was 5-foot-7 and 282 pounds, with a wedding ring the size of a quarter. He had a white beard, his face wide and warm. He wore blue jean overalls and scuffed leather work boots. He had spent most of his life as a welder, working at metal fabrication shops in and around his hometown of Circleville, Ohio, population 14,063. He was 61, nearly the same age as his father when he died from a massive heart attack. Cupp was a stoic, his daughter Chris said, but the denial worried him.

“Well, I have to call the doctor and see what we’re going to do,” he told her after the second rejection.The doctor decided to give up on getting an approval for the catheter exam. In challenging EviCore, he was fighting not just a company but an industry.EviCore is the product of a massive, decadeslong push by insurance companies to control health care costs. They point to studies that show 20% to 45% of some medical treatments are wasteful or ineffective. To decrease such spending, insurers began requiring doctors to seek permission for medical care before agreeing to pay for it — a process known as “utilization review.” As treatments became more complex, the reviews proved costly in themselves.Created from a 2014 merger of two smaller companies, EviCore offered a solution: It allowed insurers to outsource prior authorization decisions for the most specialized and expensive procedures. EviCore today issues recommendations for imaging, oncology, cardiology, gastroenterology, sleep problems and many other fields.It works with more than 100 insurers across the country, including industry titans such as UnitedHealthcare, Aetna and Blue Cross Blue Shield and some Medicare and Medicaid contractors. Cigna took over the company in 2018, but EviCore maintains its independence by blocking insurers from prying into one another’s proprietary data.In responses to inquiries, the large insurance companies said they hired EviCore as a way to make sure that customers received safe and necessary medical treatments, while holding down costs for inappropriate care.EviCore built its business by relying on different types of contracts. In one, a health insurance company pays EviCore a flat rate to review coverage requests.Another type is more lucrative, providing an incentive for EviCore to cut costs, former employees said. Known as risk contracts, EviCore takes on the responsibility for paying claims. As an example, say an insurer spends $10 million a year on MRIs. If EviCore keeps costs below that figure, it pockets the difference. In some cases, it splits the savings with the insurance company.“Where you really made your money was on a risk model,” a former EviCore executive said. “