Cigna's E/M Downcoding Policy (R49): Maryland Orders a Stop

An $80,000 Fine and a Dispute Template Every Provider Can Now Use

Rcmaxis Billing & Policy Update  ·  Posted October 13, 2026  ·  Order Date: March 13, 2026 (MIA-2026-03-009)

Summary of the Policy and the Order

Cigna's Reimbursement Policy R49, Evaluation and Management Coding Accuracy, has been in effect since October 1, 2025. It lets Cigna's internal algorithm automatically downcode professional claims billed at 99204-99205, 99214-99215, or 99244-99245, the level 4 and 5 E/M codes, when a provider's pattern of billing those codes runs consistently higher than Cigna's peer comparison, without a documentation request or clinical review first. Cigna has stated the policy targets a small share of outlier billers and that the large majority of in-network physicians are unaffected.

On March 13, 2026, the Maryland Insurance Administration issued order MIA-2026-03-009, fining Cigna $80,000 and ordering it to stop applying the policy to Maryland claims. The administration's finding was specific: automatically reducing a claim's payment based on an internal algorithm, without first disputing the claim and requesting the medical record, violates Maryland's claim-settlement statute. It's the first state enforcement action against the broader wave of payer downcoding programs that spread in 2025 and 2026, and providers in other states have started citing it as a template theory even where their own state hasn't acted yet.

What This Means for Your Claims

If you bill Cigna and see 99204-99205, 99214-99215, or 99244-99245 claims paid at a lower level than billed with no documentation request on file, that's the R49 pattern. On a specialty practice billing even 15 level-4 or level-5 visits a week to Cigna, a downcode from 99215 to 99213 can run $35-$50 per visit in lost reimbursement, which adds up to real money across a payer that size over a year, before you even start the appeal.

Practices outside Maryland don't get the order's direct protection, but the underlying problem, an insurer adjusting payment without requesting records first, is the same complaint theory now on record with a state regulator. Document the pattern and raise it through your state's insurance complaint process if Cigna's own bypass review doesn't resolve it.