Virginia: SCC faults Cigna's coverage of transgender, autism treatment

One of the state's biggest health insurers, Cigna Healthcare, treated claims for coverage of autism and transgender care unfairly, according to a State Corporation Commission Bureau of Insurance review.

The bureau also found Cigna was improperly lenient with claims for outpatient physical therapy, occupational therapy and chiropractic medical or surgical benefits.

In addition, the bureau said Cigna used unfair methods to determine what care is subject to prior authorization, concurrent review and retrospective review, as well as for how it classifies outpatient services.

The bureau's 101-page market conduct examination also found Cigna's internal monitoring to ensure coverage is not improperly restrictive for seven other services was incomplete.

In response, Cigna agreed to a 13-point corrective action plan and paid $330,000 to settle the bureau's belief that it violated state law and regulation.

It did so "solely for the purpose of a settlement and does not constitute, nor should it be construed as, an admission of any violation of law," said Katie Stewart, the company's regional vice president, in a written statement to the bureau.

The company did not immediately respond to a request for further comment.

Transgender care

The issues involved coverage for two nonmedical therapies for autism and treatment for transgender teenagers.

Insurers had for years resisted paying for "applied behavior analysis," a nonmedical therapy for autism treatment, until the General Assembly in 2011 passed a law requiring coverage.

Transgender care has become a political flashpoint, although the bureau examination started in 2022. It covered records through early 2024, well before President Donald Trump's intensified targeting of transgender people during the election campaign.

In Cigna's case, the issue involved a mastectomy for a teenager and the company's requirement for two separate letters of support — each from an independent mental health provider experienced in adolescent mental health and the diagnosis and treatment of childhood gender dysphoria — to show that coverage is medically necessary.

But the "Standards of Care for the Health of Transgender and Gender Diverse People" that the World Professional Association for Transgender Health published says a single letter from a multidisciplinary team should determine medical necessity. It says such a team should include a mental health provider, an endocrinologist, a primary care physician and others.

The bureau said that extra letter from a second mental health clinician specializing in childhood gender dysphoria — the psychological distress when assigned sex at birth does not match an individual's gender identity — is more restrictive than the usual medical standard and so is unfairly discriminatory.

Cigna said earlier guidelines from the transgender health association had required two letters, and that without more evidence it believes it would be unsafe to change from the two letters requirement.

The bureau said the insurer had misread the earlier guideline that specifically said only one letter from a qualified mental health professional was needed for mastectomy or chest reconstruction.

Loleta Keith, Cigna's senior adviser for legal compliance, wrote in response: "Our treatment decisions are guided by the best available evidence, and are intended to promote access to care while minimizing long-term untoward consequences.

"It is well-documented in the scientific literature ... that persistence of an incongruous gender identity is variable between childhood and adulthood, with some studies reporting a less than 10% persistence of a trans identity into adulthood," added Keith, citing two articles from 2008 and one from 2023.

The bureau said it looked up those articles, and noted that they appeared to rely on outdated research in some cases dating back as far as 1948.

In the end, Cigna agreed to change its requirement, saying it still disagreed with the bureau and did not consider it unduly burdensome to ask for two letters.

Autism coverage

On autism, the company accepted the bureau's corrective action to change its practice without contesting it.

The bureau found Cigna's coverage for applied behavior analysis and intensive behavioral intervention set stricter standards for paying claims than the Code of Virginia dictates. These are therapies that focus on encouraging behavior that helps people with autism communicate, improve focus and social skills, and avoid problem behaviors.

Specifically, Cigna required that "meaningful and measurable improvement is expected from the therapy," while state law says treatment must "achieve or maintain maximum functional capacity in performing daily activities."

That state standard is essentially the same as that of the national Council of Autism Service Providers.