Cigna Doctors Denied 300,000 Payment Requests in Two Months. A Judge Said a Medical Director Cannot Just Push the Button.

Suzanne Kisting-Leung was referred for a transvaginal ultrasound on August 19, 2022 because her doctor suspected she was at risk of ovarian cancer. The scan found a dermoid cyst on her left ovary. About two months later a letter arrived from radiology telling her that Cigna had denied the claim as not medically necessary, and that the $198 was hers.

Her own insurer’s published Medical Coverage Policy says a transvaginal ultrasound is medically necessary for the evaluation of suspected pelvic pathology or for screening or surveillance of a woman at increased risk for ovarian or endometrial cancer. She appealed. In November she had a second scan. That one was denied too, and in May 2023 the bill for it came to $525.

Those numbers are not ours. They are paragraphs 40 through 47 of a third amended class action complaint filed in federal court in Sacramento on June 14, 2024. We pulled the filing and read it. Everything in this file that describes what a plaintiff says happened to them comes from that document or from the court’s own order, and both are in the ledger below.

The number in the headline is a two month slice

On March 25, 2023, ProPublica published an investigation by Patrick Rucker, Maya Miller and David Armstrong into a Cigna payment review system called PxDx. The finding that travelled was this one. Over a period of two months in 2022, Cigna doctors denied more than 300,000 requests for payment through the system, spending an average of 1.2 seconds on each.

Read that as what it is. Not a lifetime total. Not an annual figure. Sixty days. One physician in the reporting, Dr. Cheryl Dopke, accounted for roughly 60,000 denials in a single month and 121,000 across the first two months of 2022. A former Cigna doctor described the mechanics to the reporters in one sentence: We literally click and submit. It takes all of 10 seconds to do 50 at a time.

The complaint quotes that same passage back at Cigna. So does the judge.

Two descriptions of the same machine

Here is what the plaintiffs say PxDx is. Paragraph 2 of the complaint: Cigna developed an algorithm known as PXDX that it relies on to enable its doctors to automatically deny payments in batches of hundreds or thousands at a time for treatments that do not match certain pre-set criteria, thereby evading the legally-required individual physician review process.

Here is what Cigna says PxDx is, on its own newsroom page, unchanged and still live. It is a simple process that has successfully helped us accelerate payments to physicians for common, relatively low-cost tests and treatments. It covers approximately 50 low-cost tests and procedures. Of claims subject to the review, 94% of claims that are subject to this review are automatically approved and paid. Denials through it represent less than 1% of our total volume of claims. And, flatly, the process does not involve algorithms, artificial intelligence, or machine learning but rather simple sorting technology that has been used for more than a decade.

Both of those can be read from a document today. Neither has been tested at trial. A reader who wants to argue that the word algorithm is doing unfair work in the headline of every story about this has a company statement to point at, and we are putting it in front of you rather than behind you.

What the plaintiffs say arrived in the mail

The complaint describes what a PxDx denial looks like from the kitchen table.

Samantha Dababneh’s doctor ordered a vitamin D test in September 2023, and the claim came back denied as not medically necessary. Two details in her allegation matter more than the amount. The denial letter indicated that the PXDX algorithm reviewed her claim. And no physician signed it. It was signed Cigna Healthcare.

Randall Rentsch was diagnosed with a herniated disk in his neck in 2016 and prescribed a series of transforaminal epidural injections. Four rounds, four denials, each one recorded in the complaint with a date. After the first two the charges stood at $5,014.80. His denial letters named PxDx as well. He says he had no idea what that string of letters meant until he read the ProPublica article seven years later, on March 25, 2023.

The plans behind these people were ordinary employer coverage. Amdocs. SunRun. Lennar Homes. Becton Dickinson. Volkswagen Group of America. Anywhere Real Estate Group. Cigna was the named claims administrator on each, which is why the case is an ERISA case and not a state contract case.

The sentence the judge wrote

Cigna moved to dismiss. On March 31, 2025 the court granted that motion in part and denied it in part, in a 27 page order signed by District Judge Dale A. Drozd. We read the order.

Cigna’s argument on the fiduciary duty count was that its plans were satisfied. The plan says a medical director determines medical necessity. A medical director signs. Therefore a medical director determined.

The court would not have it. It found Cigna’s interpretation of the clause requiring that medical necessity determinations be made by a medical director, read as allowing an algorithm to make the decision so long as a medical director pushes the button, to conflict with the plain language of the plan and to constitute an abuse of discretion.

That is the whole ballgame for anyone who has ever received a denial letter with a doctor’s name on it and no evidence a doctor was there. A signature is not a review. At least one federal judge has now put that in writing.

Who is actually left in the case

This is where most coverage stopped and where the record gets less flattering to the plaintiffs.

The order dismissed the claim for benefits under 29 U.S.C. 1132(a)(1)(B) as to every plaintiff, with leave to amend. On the breach of fiduciary duty claim under 29 U.S.C. 1132(a)(3), the court found there is no genuine dispute that the claims of plaintiffs Kisting-Leung, Thornhill, and Bredlow were not subjected to PxDx review, so those three lack standing on it. Their claims were dismissed with leave to amend and the count proceeds for the other three. On the California unfair competition claim the same three were cut, and Rentsch was cut as untimely, leaving two.

So Suzanne Kisting-Leung, whose two denied ultrasounds open this file, is on the record as someone whose claims the court found were not run through PxDx. Her bills are real and documented. The link between those bills and the system in the headline is the part that did not survive that order. We are telling you that rather than letting you find it.

The California rule the complaint leans on

The unfair competition count borrows a state health law. California Health and Safety Code section 1367.01(e) reads: No individual, other than a licensed physician or a licensed health care professional who is competent to evaluate the specific clinical issues involved in the health care services requested by the provider, may deny or modify requests for authorization of health care services for an enrollee for reasons of medical necessity.

The statute is about authorization requests. Cigna’s answer to the original reporting was that PxDx is not prior authorization at all, because it runs after the patient has already received care. Whether a post-service payment review is caught by a pre-service statute is a live question in the case, not a settled one.

What Washington did about it

The reporting produced the reaction you would expect and less follow-through than you would hope. On May 16, 2023, ProPublica and The Capitol Forum reported that House Energy and Commerce chair Cathy McMorris Rodgers had demanded documents from Cigna, including copies of all memoranda analyzing the legality of the PXDX review process. The Washington state insurance commissioner at the time, Mike Kreidler, called the practice abhorrent. The California Department of Insurance said it was looking closely at health insurance companies’ handling of claims. Two accreditation bodies, URAC and the National Committee for Quality Assurance, opened reviews.

We could not open the committee letter itself. The House server refuses automated readers. That paragraph is sourced to the journalists who did read it, and the ledger says so.

What we do not know

The docket after March 31, 2025. Plaintiffs had 21 days to file a fourth amended complaint or to proceed on what survived, and the court set an initial scheduling conference for June 9, 2025. What happened next is behind PACER, and the two free mirrors that carry this case both refused us. No class has been certified as far as this file knows. No liability has been found. Nobody has paid anybody.

If you want the version of this story where a machine was caught and punished, it does not exist yet. What exists is a count, a stopwatch, a company denial, and one judge who read a contract literally.

What to do with a denial letter that names a system

Look at the signature block. Dababneh’s alleged letter was signed by a company, not a person. Look for a code. Both Dababneh and Rentsch say their letters named PxDx outright, which means the disclosure sometimes happens and is worth hunting for. Then appeal, because a denial produced by a code mismatch is the kind that a corrected code can reverse. Cigna itself says so, describing claims that can be resubmitted with an updated diagnosis code and paid.

The same arithmetic runs through public coverage from the other direction. Our file on Medicare Advantage nursing home denials found federal auditors counting 13,458 denials in a single month and 2,445 appeals, and plans reversing almost every appeal they decided. The pattern is the same in both books of business. The denial is cheap to issue. The appeal is expensive to ignore. Most people never send one.