What EviCore is, who hired them, and what to do about it. Over 100 insurance companies outsource prior authorization decisions to a company most patients have never heard of.
EviCore by Evernorth is a medical benefits management company owned by Cigna. Insurers hire them to review prior authorization requests. When your insurance says no, there is a real chance EviCore said it — not your insurer. EviCore manages coverage decisions for roughly 1 in 3 insured Americans: over 100 million people.
A 2024 investigation by ProPublica and the Capitol Forum found that EviCore markets itself to insurers by promising a 3-to-1 return on investment. That means for every dollar an insurer spends on EviCore, they expect to pay out three dollars less in medical care. EviCore salespeople have reportedly boasted of achieving a 15% increase in denials for their clients.
If you are covered by any of the following, there is a real chance EviCore has reviewed or will review your prior authorization:
If you receive a denial and the paperwork mentions EviCore, Evernorth, or refers to "medical benefits management," now you know who you are actually dealing with.
EviCore denials follow a pattern — and patterns can be countered. The most common denial reason is "missing information" or "not medically necessary." In practice, this usually means the clinical language EviCore's algorithm needs to approve the request was not in your doctor's documentation when the prior auth was submitted. This is not your doctor's fault. Prior authorization criteria are not taught in medical school. Physicians are not given EviCore's internal guidelines.
