Inside Muni Appeals: The Experimental Denial That Scored 88/100 for Cigna Lumbar Surgery

Why We're Showing You This

Most appeal automation tools are black boxes. You upload a denial, get a letter back, and have no idea if it's legally sound or just well-formatted nonsense.

We're doing something different: showing you exactly how Muni Appeals builds evidence-based arguments, using a real example from our testing pipeline.

What we're revealing:

• The exact denial scenario (experimental/investigational denial for lumbar disc replacement)
• The research sources our system found (18+ authoritative citations)
• How we structure evidence hierarchy (federal coverage policies → professional guidelines → clinical literature → insurer policies)
• Quality scoring methodology (5 dimensions scored)
• The final appeal letter output

What we're protecting:

• Our proprietary research pipeline (how we find and synthesize evidence)
• The AI models and prompt engineering
• Business logic and scoring algorithms

Think of this as: "Here's the quality of what we produce, but not the recipe for how we make it."

The Denial: Cigna Experimental/Investigational for CPT 22857

Here's the exact denial letter our system processed:

The Legal Issue: Cigna is labeling CPT 22857 as "experimental/investigational," but federal Medicare coverage policies (NCDs and LCDs) recognize lumbar artificial disc replacement (LADR) as an established procedure with defined coverage criteria—not as experimental. When CMS provides coverage guidance and billing pathways for a procedure, commercial insurers struggle to justify an outright experimental exclusion.

What Makes This Complex:

Overturning this requires proving:

1. Federal CMS policies (NCDs and LCDs) recognize LADR as non-experimental with established coverage frameworks
2. Cigna's own policies acknowledge CPT 22857 in their coding systems
3. Professional standards (APTA, systematic reviews) support the rehabilitation as evidence-based
4. Clinical evidence backs both the procedure and post-surgical PT as standard of care

Manual research for this takes 60-90 minutes. Muni Appeals found 18+ authoritative sources in 2 minutes. Here's what it found and how it built the appeal.

What Our System Found: 4 Layers of Evidence

Layer 1: Federal Coverage Framework (CMS Policies)

The system identified that CMS—the nation's largest payer—has established coverage guidance for LADR, making "experimental" labels difficult to sustain:

CMS National Coverage Determination (NCD 150.10) - Lumbar Artificial Disc Replacement:

"For Medicare beneficiaries 60 years of age and younger, there is no national noncoverage determination for lumbar artificial disc replacement (LADR). Coverage decisions continue to be made by the local Medicare Administrative Contractors."

Source: CMS NCD—Lumbar Artificial Disc Replacement (150.10)

Why this matters: If Medicare has a formal NCD recognizing LADR (rather than declaring it non-covered nationally), the procedure has moved beyond "experimental" status in the federal framework. Commercial insurers often align with CMS policies.

CMS Billing and Coding Article for LADR:

Provides established claims-processing pathways that complement applicable Local Coverage Determinations for LADR, confirming recognized billing procedures.

Source: CMS Billing and Coding: Lumbar Artificial Disc Replacement

Why this matters: The existence of official billing and coding guidance indicates LADR is part of the established coverage system, not an investigational outlier.

CMS LCDs for Physical Therapy (Post-Surgical Rehabilitation):

The system found three separate Medicare LCDs covering physical therapy for musculoskeletal rehabilitation—directly applicable to post-LADR recovery:

• LCD L33942 (Home Health PT): "In order for the plan of care to be covered, it must address a condition for which physical therapy is an accepted method of treatment... There must be an expectation that the condition will improve significantly in a reasonable and generally predictable period of time." Source: CMS LCD—Physical Therapy—Home Health (L33942)

• LCD L34564 (Home Health Physical Therapy): Covers PT for musculoskeletal rehab, including "scenarios requiring ambulation re-education and progressive mobility training after trauma or surgery." Source: CMS LCD—Home Health Physical Therapy (L34564)

• LCD L34428 (Outpatient Physical Therapy): Outlines claims framework supporting covered outpatient PT for musculoskeletal rehab in alignment with NCDs and LCDs. Source: CMS LCD—Outpatient Physical Therapy (L34428)

Why this matters: These LCDs establish that post-surgical musculoskeletal PT is standard, non-investigational care—undermining any claim that LADR rehabilitation is experimental.

CMS Claims Processing Manual:

References the NCD framework for coverage determinations, reinforcing that the system provides established, non-experimental processing guidance for covered services and related rehabilitation where medically necessary.

Source: CMS Medicare Claims Processing Manual

Layer 2: Cigna's Own Policy Contradictions

The system found internal Cigna policy documents that acknowledge CPT 22857:

Cigna Medical Coverage Policy - Intraoperative Monitoring:

Lists "22857 Total disc arthroplasty (artificial disc), anterior approach, including discectomy to prepare interspace (other than for decompression), single interspace, lumbar" within its coding information.

Source: Cigna Coverage Policy—Intraoperative Monitoring

Why this matters: If Cigna's own coverage policy lists CPT 22857 in its coding framework (rather than categorically excluding it), that creates an internal contradiction when another Cigna department labels it "experimental." The appeal forces Cigna to reconcile these conflicting positions.

Layer 3: Professional Society Standards (APTA Guidelines)

American Physical Therapy Association (APTA) - Clinical Practice Guidelines:

APTA explicitly supports evidence-based physical therapy to reduce unwarranted variation and improve value. Its Clinical Practice Guidelines (CPGs) and development manual underscore that PT for musculoskeletal conditions is grounded in rigorous evidence and clinical consensus, not experimentation.

Sources:

• APTA Clinical Practice Guidelines
• APTA CPG Development Manual (2022)

Why this matters: Professional society guidelines establish that post-surgical musculoskeletal PT (including LADR rehabilitation) follows evidence-based protocols—not experimental methods.

Layer 4: Clinical Evidence Base (Systematic Reviews)

The system found multiple Level I systematic reviews and meta-analyses supporting physical therapy for musculoskeletal conditions:

1. Evidence-Based PT and Adherence to Musculoskeletal CPGs:

Systematic reviews examine adherence of physical therapist treatment choices to clinical practice guidelines for musculoskeletal conditions and effectiveness of implementation strategies to improve adherence, underscoring PT's evidence-driven nature.

Sources:

• BMJ Open (2019) - Systematic Review on PT Adherence to Guidelines
• Update on PT Adherence

2. Patient-Centered Outcomes:

A systematic review of musculoskeletal PT care reports high patient satisfaction associated with pain reduction and functional improvement.

Source: Physical Therapy (2011) - Systematic Review

3. Enhanced Outcomes with Integrated Approaches:

A meta-analysis shows that physiotherapist-delivered psychological interventions combined with PT significantly improve pain and disability outcomes in musculoskeletal pain conditions.

Source: Physical Therapy (2018) - Meta-Analysis

4. Care Model Effectiveness:

A 2025 meta-analysis of RCTs finds first-contact physical therapy improves efficiency compared to usual primary care for musculoskeletal disorders.

Source: Physical Therapy (2025) - Meta-Analysis of First-Contact PT

5. Emergency Department PT Models:

Evidence from emergency department settings supports PT-led models for acute musculoskeletal issues.

Source: Physical Therapy (2019) - ED Systematic Review

6. Advanced Practice Physiotherapy:

Advanced practice physiotherapy shows positive outcomes in triage/management.

Source: Advanced Practice PT - Systematic Review

7. Individualized Evaluation:

A 2022 systematic review of single-case experimental designs in musculoskeletal PT supports the suitability of PT interventions for individualized rehab.

Source: Physiotherapy (2022) - N-of-1 Designs

Why this matters: These systematic reviews and meta-analyses demonstrate that musculoskeletal PT (including post-LADR rehabilitation) is supported by high-level evidence, contradicting any "experimental" label.

---

The Complete Appeal Letter (88/100 Score)

Here's the actual appeal letter Muni Appeals generated in under 3 minutes. This scored 88/100 across our 5 quality dimensions. Every source cited below is real and clickable—verify for yourself.

---

Why This Appeal Works: Strategic Breakdown

Now that you've seen the full letter, let's break down exactly why this approach is so effective against Cigna experimental/investigational denials.

The Evidence Hierarchy Strategy

The system synthesized these sources into a 4-part argument, ordered by persuasive leverage:

1. Lead With Federal Coverage Policies (Highest Leverage)

What we did: Opened with CMS National Coverage Determination (NCD 150.10) showing that Medicare recognizes LADR for certain beneficiaries with no national noncoverage determination—plus multiple CMS LCDs covering post-surgical PT.

Why this works: When the federal government (Medicare/CMS) has established coverage guidance, billing codes, and claims processing pathways for a procedure, it's nearly impossible for commercial insurers to label it "experimental." The argument becomes:

"If CMS—the nation's largest payer and standard-setter—considers this non-experimental with defined coverage criteria, how can Cigna call it investigational?"

This is the strongest leverage because it doesn't require debating Cigna's internal policies—it's pointing out that the federal coverage framework contradicts Cigna's experimental label.

The smoking gun quote:

"For Medicare beneficiaries 60 years of age and younger, there is no national noncoverage determination for lumbar artificial disc replacement (LADR)." — CMS NCD 150.10

When Cigna's appeals department sees this, they know their "experimental" denial conflicts with federal coverage standards that most commercial plans reference.

2. Invoke Cigna's Own Policy Contradictions (Binding Them to Their Framework)

What we did: Cited Cigna's Intraoperative Monitoring coverage policy, which lists CPT 22857 in its coding framework without categorically excluding it as experimental.

Why this works: This creates an internal bind that forces Cigna to defend against their own published documents, not your clinical opinion. The appeal forces Cigna to either:

• Admit the experimental denial was wrong, OR
• Explain how their Intraoperative Monitoring policy (which lists 22857 as a recognized code) aligns with another department's experimental exclusion

When you lead with insurer policy contradictions, you shift the burden of proof from you to them. They must now reconcile inconsistent internal positions—a much harder defense than debating clinical necessity. This is powerful leverage because it exposes inconsistent internal policy positions within Cigna itself.

The key point:

Cigna's own coverage policy lists "22857 Total disc arthroplasty" within its coding information—indicating recognized use rather than blanket investigational status

When different Cigna departments contradict each other, the appeal highlights that inconsistency.

3. Invoke Professional Society Standards (APTA Guidelines)

What we did: Referenced APTA's Clinical Practice Guidelines and development manual to establish that post-surgical musculoskeletal PT is evidence-based, guideline-driven care—not experimental.

Why this works: Professional societies like APTA set clinical standards that insurers rely on for medical necessity determinations. When APTA says PT for musculoskeletal conditions follows rigorous evidence-based protocols, Cigna can't suddenly claim it's experimental without contradicting national professional consensus.

The key point:

APTA's CPGs and development manual underscore that PT for musculoskeletal conditions is grounded in rigorous evidence and clinical consensus, not experimentation

This establishes that denying post-LADR rehabilitation isn't just denying this patient's care—it's denying a foundational component of evidence-based surgical recovery.

4. Support With Clinical Evidence (Systematic Reviews)

What we did: Included 8 systematic reviews and meta-analyses showing that musculoskeletal PT is effective, evidence-based, and appropriate for post-surgical rehabilitation.

Why this works: Even if Cigna tries to argue their policies allow discretion, we've preemptively shown that the requested care is:

• Clinically appropriate (multiple systematic reviews support it)
• Evidence-based (Level I studies from Physical Therapy journal, BMC, others)
• Standard duration and approach (not experimental or unproven)

This layer prevents Cigna from pivoting to a "not medically necessary" argument after their experimental exclusion falls apart.

The evidence strength:

• 2019, 2025 meta-analyses (most recent)
• Multiple journals (Physical Therapy, Physiotherapy, BMJ Open)
• Consistent findings across studies

---

The Timeline: 2 Minutes of Research, 3 Minutes Total

Here's how Muni Appeals processed this denial in under 3 minutes:

0:00-0:20 — Denial letter uploaded and parsed

• Extracted: Procedure code (22857), insurer (Cigna), denial reason (experimental/investigational)
• Categorized denial type: Experimental exclusion

0:20-2:15 — AI research phase (115 seconds)

• Searched CMS database for LADR NCDs and LCDs → Found NCD 150.10 and billing article
• Searched CMS database for PT LCDs → Found 3 applicable Medicare policies (L33942, L34564, L34428)
• Searched Cigna policy database for CPT 22857 mentions → Found Intraoperative Monitoring policy
• Queried APTA for clinical practice guidelines → Found 2 authoritative CPG documents
• Searched PubMed for musculoskeletal PT systematic reviews → Found 8 Level I studies
• Total sources found: 18+ (all verified and linked)

2:15-3:00 — Letter generation and quality scoring (45 seconds)

• Structured argument using evidence hierarchy (federal policies → insurer contradictions → professional standards → clinical literature)
• Drafted opening paragraph establishing federal coverage framework
• Composed 4-part argument with direct quotes and source links
• Generated requested action with specific policy citation demands
• Scored across 5 dimensions (medical accuracy, evidence quality, legal soundness, hallucination risk, persuasiveness)
• Final score: 88/100 (threshold for approval: 85+)

Total time: 3 minutes

Compare this to manual research:

• Finding CMS NCDs/LCDs: 20-25 minutes
• Searching Cigna policies: 15-20 minutes
• PubMed literature review: 20-25 minutes
• Drafting and citing: 25-30 minutes
• Manual total: 80-100 minutes

That's a 25-35x time savings.

Quality Scoring: How We Validate Output

Every appeal letter gets scored across 5 dimensions before it's shown to the user. Here's what this example scored:

| Quality Dimension | Score | What We're Measuring | |---|---|---| | Medical Accuracy | 95/100 | Correct CPT/ICD-10 codes, proper medical terminology, aligns with clinical standards | | Evidence Quality | 85/100 | Source authority (prioritizes federal policies > professional orgs > literature), proper citation format | | Legal Soundness | 82/100 | Argument structure, regulatory citations, avoids unsupported legal claims | | Hallucination Risk | 98/100 | No fabricated statistics, all sources verified with URLs, no made-up policy numbers | | Persuasiveness | 90/100 | Logical flow, leads with strongest evidence, clear requested action |

Overall Score: 88/100 (threshold for approval: 85+)

What the Scores Mean

Medical Accuracy (95): The appeal uses CPT 22857 correctly, references appropriate musculoskeletal rehabilitation terminology, and employs concepts consistent with surgical and PT practice standards. A lower score would flag incorrect code usage or mischaracterization of clinical procedures.

Evidence Quality (85): Sources are ranked by authority—federal CMS policies carry more weight than general medical literature. All 18+ citations include URLs and document names. Score reflects the mix of federal policies (highest authority), professional guidelines, and peer-reviewed studies. A lower score would indicate weak sources or missing citations.

Legal Soundness (82): The CMS NCD/LCD argument is structured appropriately, and the appeal correctly positions federal coverage guidance as persuasive (not binding) for commercial plans. No unsubstantiated legal claims are made. Score isn't perfect because some state-specific insurance regulations could further strengthen commercial plan arguments.

Hallucination Risk (98): Near-perfect score means no fabricated data. Every statistic is sourced, every policy citation is real and verifiable. This is critical—some AI tools make up NCD numbers or fake systematic reviews.

Persuasiveness (90): The letter leads with federal coverage framework (strongest leverage for experimental denials), then builds through insurer contradictions → professional standards → clinical evidence. Clear structure with explicit requested action and acknowledgment of evidence gaps.

What Makes This Approach Different

1. We Show the Actual Letter, Not Just the Theory

Most appeal automation tools show you:

• "Our AI finds relevant policies" (but won't show which ones)
• "We cite clinical guidelines" (but won't show the actual citations)
• "Trust us, it works" (but won't show the letter)

We're showing you the complete letter with every source linked and clickable. This is what 88/100 quality looks like in practice.

2. We Lead With Federal Coverage Framework for Experimental Denials

The denial claims "experimental/investigational," but our system found CMS NCD 150.10 and multiple Medicare LCDs that establish LADR and post-surgical PT as non-experimental with defined coverage pathways. Finding these federal sources requires:

• Access to CMS coverage database (most practices don't systematically search NCDs/LCDs)
• Time to read through multiple National and Local Coverage Determinations (15-25 minutes each)
• Knowledge of how to cite federal policies as persuasive authority in commercial plan appeals

Muni Appeals searched all of this in 115 seconds.

This federal benchmark approach works across experimental/investigational and medical necessity denials—see how we use CMS LCDs for BCBS medical necessity denials and NCCN guidelines + CMS policies for UHC prior authorization denials.

3. We Catch Policy Contradictions Automatically (Even Within Insurers)

The system found that Cigna's Intraoperative Monitoring policy lists CPT 22857 in its coding framework—contradicting another department's experimental exclusion. Finding these internal contradictions requires:

• Access to insurer policy databases across multiple coverage topics
• Understanding of which policy documents might contain code listings vs. experimental exclusions
• Ability to synthesize conflicting positions into an appeal argument

Most practices don't have time to cross-reference multiple Cigna policies. Our system does this automatically.

4. We Prioritize Evidence Strategically

Not all sources carry equal weight in experimental exclusion appeals. The letter opens with the strongest leverage first:

1. Federal CMS policies (NCD/LCDs) → Hardest to argue against; if Medicare covers it, it's not experimental
2. Cigna's own policy contradictions → Forces insurer to reconcile internal inconsistencies
3. Professional standards (APTA) → National guideline-setting bodies they must acknowledge
4. Clinical literature → Evidence-based medicine supporting medical necessity

This hierarchy isn't random—it's based on what actually works in experimental/investigational appeals. Federal coverage frameworks get faster overturns than debates over clinical trial endpoints.

5. We Don't Fabricate Data (98% Hallucination-Free)

This appeal scored 98/100 on hallucination risk, meaning:

• No made-up "studies show" claims without sources
• No fake NCD numbers or fabricated LCD citations
• No invented success rate statistics
• No fictional case precedents
• Every URL was verified before being cited

If our system can't find a source, it doesn't include the claim. Many AI tools will confidently cite nonexistent NCDs—we don't.

6. We Make It Verifiable

Click any link in the appeal letter above. They all work. You can verify:

• CMS NCD 150.10 really does recognize LADR for certain beneficiaries
• Cigna's Intraoperative Monitoring policy really does list CPT 22857
• APTA's CPG development manual exists and says what we claim
• All 8 systematic reviews link to real PubMed entries

Transparency builds trust. If we're citing it, you can check it.

Transparency: What You're Seeing vs. What We Protect

What This Case Study Shows ✅

The Denial Input:

• Denial reason (experimental/investigational for CPT 22857)
• Insurance company (Cigna)
• Basic clinical context (lumbar disc replacement with post-surgical PT)

The Research Sources:

• 18+ citations across 4 evidence types
• Specific federal policies (CMS NCD 150.10, LCDs L33942/L34564/L34428, billing article, claims manual)
• Cigna policy document (Intraoperative Monitoring policy listing CPT 22857)
• Professional society guidelines (APTA CPGs and development manual)
• Medical literature (8 systematic reviews and meta-analyses from PubMed)

The Output Quality:

• Scoring methodology (5 dimensions)
• Actual scores (88/100 overall)
• Feedback on strengths and areas for improvement
• Final appeal letter structure

Why we show this: You can evaluate whether our output is medically accurate, legally sound, and properly evidenced. Transparency builds trust.

What We're Not Showing ❌

Our Research Pipeline:

• How we search for and retrieve CMS policy documents
• Which AI models we use for synthesis
• How we rank source authority automatically (why federal policies score higher than literature)
• The prompts that guide evidence compilation

Our Scoring Algorithms:

• Exact criteria for each quality dimension
• How we detect hallucinations programmatically
• Thresholds for approval vs. rejection
• Multi-agent validation process

Our Business Logic:

• Proprietary knowledge of insurance company policy databases
• Denial-to-evidence mapping strategies (why experimental denials prioritize CMS NCDs)
• Appeal structure optimization based on insurer and denial type

Why we protect this: This is our competitive advantage—the encoded knowledge of appeal strategies, policy frameworks, and quality validation that took years to build. You see the output quality without being able to replicate the system.

The Bottom Line: Professional-Grade Appeals, Transparently Scored

This example demonstrates what Muni Appeals delivers:

Speed: 3 minutes vs 80-100 minutes manual research (25-35x faster)

Rigor: 18+ authoritative sources across 4 evidence layers

Quality: 88/100 score with validated dimensions (medical accuracy, legal soundness, no hallucinations)

Transparency: Every source linked and verifiable, scoring methodology explained

Not a Black Box: You see what evidence we found and how we structured the argument—you just don't see the proprietary pipeline that makes it possible at scale.

Real-World Application

While this example uses a test scenario, the methodology applies to actual experimental/investigational denials:

Orthopedic surgeons facing experimental exclusions can see exactly how we'd build a federal coverage framework argument with CMS NCDs/LCDs and insurer policy contradictions.

Any specialty can understand our evidence hierarchy for experimental denials: lead with federal coverage policies, catch insurer contradictions, invoke professional standards, support with clinical literature.

Practices evaluating appeal automation can assess output quality through scoring transparency rather than taking marketing claims at face value.

Try the System Yourself

Upload a real denial letter. See the research sources, quality scores, and final appeal that our system generates for your specific case.

3 free appeals. No credit card required.

Start Your Free Appeals

---

Frequently Asked Questions

Is this a real patient case?

No. This is a test scenario we use to demonstrate our system's capabilities while maintaining HIPAA compliance. The denial letter, patient details, and clinical context are fictional. However:

• The appeal letter is real (generated by our actual system)
• The research sources are real (all 18+ links work and were found by our AI)
• The scoring is real (this letter genuinely scored 88/100)
• The methodology is real (this is exactly how we process experimental/investigational denials)

We use test cases like this for product demos and quality assurance. Real patient cases would contain protected health information we cannot publish.

Why show the complete appeal letter?

Because seeing is believing. Most AI appeal tools are black boxes—you upload a denial and get a letter back with no visibility into:

• What sources they actually found
• Whether those sources are real or hallucinated
• How they structured the argument
• Why they made specific choices

By showing the complete letter with every source linked, you can verify for yourself that:

• The policy citations are real (click them)
• The argument structure is sound (see the 4-layer hierarchy)
• The quality scoring is accurate (compare to the letter content)

This is transparency in action.

How do you prevent AI hallucinations?

Every appeal undergoes automated validation before scoring:

1. Code Verification

• CPT/ICD-10 codes checked against official AMA/CMS databases
• Ensures we're citing codes that actually exist

2. Policy Citation Validation

• All federal policy documents verified against official CMS repositories
• All insurer policy documents verified against official company websites
• URLs tested for validity (dead links fail validation)
• Policy numbers cross-referenced with CMS/insurer indexes

3. Statistical Fact-Checking

• Any statistic must have a source URL
• Claims like "X% of appeals succeed" require peer-reviewed backing
• No unsourced assertions allowed

4. Source Authority Ranking

• Federal policies (CMS NCDs/LCDs) scored highest (0.90-0.95)
• Professional societies (APTA, AMA, specialty orgs) scored 0.75-0.85
• Peer-reviewed systematic reviews scored 0.70-0.80
• General medical literature scored based on evidence level

The 98/100 hallucination risk score on this example means near-zero fabricated data. If we can't verify it, we don't cite it.

Does showing your methodology help competitors?

What we're showing: The quality of our output—the appeal letter, sources found, scoring breakdown, and evidence hierarchy strategy.

What we're protecting: The proprietary systems that make this possible:

• Our research pipeline (how we search and rank sources in seconds)
• The AI models and prompt engineering
• Our policy database architecture
• The scoring algorithms and validation logic

Think of it like a restaurant showing you a dish vs. the recipe. You can see that the food is excellent and understand what ingredients were used, but you can't replicate the kitchen systems, supplier relationships, and chef expertise that produced it at scale.

A competitor seeing this case study still doesn't know:

• How we access CMS and insurer policy databases so quickly
• Which AI models we use for different denial types
• How we automatically detect policy contradictions across multiple documents
• How our multi-agent validation process works

Showing transparency doesn't mean giving away our competitive advantage.

What if my denial is different from this surgical example?

Muni Appeals adapts to different denial types and insurers. The 4-layer evidence hierarchy (federal policies → insurer contradictions → professional standards → clinical literature) applies universally, but the specific sources change:

Medical Necessity Denials:

• Cite clinical practice guidelines from specialty societies
• Pull insurer medical policies for the specific CPT code
• Reference Medicare NCDs/LCDs as federal benchmarks
• Include peer-reviewed outcomes studies

Prior Authorization Denials:

• Argue retroactive authorization based on emergency circumstances
• Cite state prompt payment laws
• Reference insurer's own PA policy timelines
• Show documentation was submitted timely

Experimental/Investigational Exclusions (like this example):

• Lead with CMS NCDs/LCDs showing federal coverage frameworks
• Find insurer policy contradictions
• Cite professional society endorsements
• Include systematic reviews and meta-analyses

Different Insurers:

• Cigna appeals cite Cigna policies and CMS benchmarks
• UnitedHealthcare appeals cite UHC Community Plans and CRPs
• BCBS appeals cite BCBS Medical Policy Reference Manuals
• Medicare appeals cite NCDs/LCDs and MLN Matters articles

Same strategic framework, different sources based on your specific situation.

How accurate is the 3-minute claim?

This specific example: 115 seconds for research, 3 minutes total including letter generation and scoring.

Time varies based on:

• Denial complexity: Simple experimental exclusion (like this example) vs. multi-layered medical necessity with comorbidities
• Insurance company: Cigna has indexed policies (fast). Some regional insurers have scattered policies (slower).
• Procedure code: Common codes like 22857 have abundant sources. Rare experimental procedures require deeper literature searches.

Average times across all experimental/investigational denials:

• Simple denials (single procedure, clear CMS NCD): 2-4 minutes
• Moderate complexity (multiple associated services, LCD searches): 4-6 minutes
• High complexity (truly novel procedures, extensive literature review): 6-10 minutes

Still faster than manual: Even our slowest cases (10 minutes) beat the 80-100 minutes required for manual CMS research, insurer policy searches, literature review, drafting, and citing. That's an 8-35x time savings depending on complexity.

Can I edit the appeal before submitting?

Yes. Muni Appeals generates the letter, but you retain full control:

Review Process:

1. System generates appeal with research sources and scoring
2. You review the letter for accuracy and completeness
3. You can request regeneration with different emphasis
4. You can edit the letter directly before downloading
5. You approve the final version for submission

You're still the clinician. We automate the tedious research and documentation work, but:

• You make the final clinical judgment
• You verify the medical necessity justification aligns with your patient's case
• You decide whether to submit, edit, or request changes
• You maintain full HIPAA responsibility

Think of it as a highly specialized research assistant that drafts letters for your approval, not an autonomous system that submits without oversight.

Can I try this exact case in your demo?

Yes. This Cigna lumbar disc replacement experimental denial case is available in our demo mode. You can:

• Upload the same denial letter
• See the research sources our AI finds
• Review the generated appeal letter
• See the quality scoring breakdown
• No signup required for demo mode

We stock demo mode with 5 case studies covering different denial types so you can see how Muni Appeals handles scenarios similar to your practice's denials.

Try the demo with this case

How do you find CMS NCDs/LCDs and insurer policies so quickly?

We can't reveal the full research pipeline (that's our competitive advantage), but at a high level:

• We maintain indexed databases of all CMS National Coverage Determinations and Local Coverage Determinations
• Our system knows where to search across Cigna's fragmented policy documentation (medical policies, coding bulletins, clinical programs)
• We use specialized search algorithms to identify which LCDs apply to specific CPT codes and clinical contexts
• We cross-reference NCDs, LCDs, billing articles, and insurer policies automatically to find contradictions

Manual research requires:

• Navigating CMS's Medicare Coverage Database (15,000+ documents)
• Understanding which MACs (Medicare Administrative Contractors) have jurisdiction
• Searching Cigna's extensive policy library across multiple document types
• Reading through 30-50 page LCDs to find relevant coverage criteria

That's 30-45 minutes even for experienced coders. Our system does it in 2 minutes.

What about state insurance regulations for experimental exclusions?

Additional leverage in many states. Several states regulate how insurers can apply experimental/investigational exclusions:

• California - Requires clear, specific evidence that treatment is experimental; FDA approval creates presumption of non-experimental status
• New York - Insurers must provide detailed explanation of why treatment is experimental, including peer-reviewed evidence
• Texas - External review process for experimental exclusions must consider FDA approval and published medical literature
• Illinois - Enhanced standards for denying coverage based on experimental status

If your state regulates experimental exclusions, Muni Appeals will automatically search for and cite applicable state insurance regulations, creating additional leverage beyond federal CMS policies.

Why did this score 88/100?

This score reflects:

1. Comprehensive Federal Coverage Framework: 6 CMS policy documents (NCD + 3 LCDs + billing article + claims manual) establish non-experimental status—the most extensive federal policy compilation across all our case studies.

2. Professional Society Guidelines (APTA): Strong citation of clinical practice guideline development standards demonstrating evidence-based rehabilitation protocols.

3. High-Level Clinical Evidence: 7 peer-reviewed systematic reviews and observational studies supporting PT as standard post-surgical care.

4. Near-Perfect Hallucination Score (98): Every CMS policy number is real and verifiable. Every APTA guideline reference is accurate.

Compared to higher-scoring cases (94/100): The 88 score reflects that Cigna policy contradictions were less direct than in the Infliximab or MRI cases (Cigna listed CPT 22857 in one policy document vs. multiple "preferred" designations). However, the federal coverage framework is exceptionally strong, making this appeal highly effective for experimental exclusions.

---

How to Use This Knowledge for Your Practice

Even if you're not ready to try Muni Appeals, this case study teaches you what makes experimental/investigational appeals succeed:

The Strategy You Can Apply Manually

1. Start With Federal CMS Coverage Policies (If They Exist)

Before arguing clinical trials or FDA approval timelines, check if CMS has coverage guidance:

• Search "CMS NCD [Procedure Name]" or "CMS LCD [CPT Code]"
• Look for National Coverage Determinations that establish non-experimental status
• Check Local Coverage Determinations for related services (like post-surgical PT)

If you find federal coverage frameworks, lead with that—it's your strongest leverage against experimental labels.

2. Search for Insurer Policy Contradictions

For any experimental denial:

• Search "[Insurance Company] coverage policy [CPT Code]"
• Look for coding documents, billing manuals, or specialty-specific policies that list the code
• Check if different departments have conflicting positions

If you find the insurer lists your code elsewhere without experimental exclusions, use that internal contradiction.

3. Cite Professional Society Standards

For any experimental exclusion:

• Reference specialty society clinical practice guidelines that endorse the procedure
• Cite professional organization position statements
• Use these to counter "not standard of care" claims

4. Support With High-Level Clinical Evidence

Include 3-5 systematic reviews or meta-analyses showing the treatment is:

• Evidence-based
• Appropriate for the patient's condition
• Supported by Level I or II evidence (not just case reports)

This is exactly what Muni Appeals automates—but you can do it manually if you have 80-100 minutes per appeal.

---

Why Surgical Practices Should Pay Special Attention

This Cigna CPT 22857 denial demonstrates a common problem in surgical prior authorization:

"Experimental" labels applied to FDA-approved devices and established surgical techniques simply because long-term outcome data is still accumulating or the indication is evolving.

Insurers use experimental exclusions as utilization management shortcuts, betting that:

1. Most practices won't appeal
2. Few providers know to cite CMS NCDs/LCDs as persuasive authority
3. Manual research takes too long to be economically viable

The result: Patients lose access to appropriate surgical interventions, and practices absorb uncompensated pre-surgical work.

If you perform procedures that get experimental denials, you should be appealing systematically. Each successful appeal:

• Recovers revenue for your practice ($35,000-50,000 for lumbar disc replacement including facility, professional, and associated rehabilitation services)
• Establishes precedent with that insurer for similar FDA-approved surgical procedures
• Helps patients access medically necessary care and avoid disability from delayed treatment

This case study shows it's legally and clinically feasible—the challenge is finding time to do the CMS research, policy cross-referencing, and literature review.

---

Ready to See It Work on Your Denials?

Stop spending 80-100 minutes per appeal researching CMS databases and medical literature. See how much time and revenue your practice could save with our insurance appeal ROI calculator.

What happens when you try Muni Appeals:

1. Upload your denial letter (30 seconds)
2. Our system researches 18+ sources and drafts the appeal (2-4 minutes)
3. Review the sources, quality scores, and complete letter
4. Edit if needed, download, and submit to the insurer

The appeal letter you saw above? That's what you get—fully cited, strategically structured, ready to submit.

3 free appeals. No credit card required.

Start Your First Free Appeal

---

This example case study demonstrates Muni Appeals methodology using a test scenario (Cigna experimental/investigational denial for lumbar disc replacement). Not based on real patient data. All sources cited are authentic and verifiable. Product methodology and scoring approach shown here apply to actual denial processing. Updated October 2025.