“Not Medically Necessary”: Inside the Company Helping America’s Biggest Health Insurers Deny Coverage for Care

GAINING CLARITY: A ProPublica investigation reveals how EviCore, a company hired by major U.S. insurers, uses algorithms and financial incentives to deny patient healthcare coverage. EviCore’s practices, including manipulating an internal algorithm to increase denials, have drawn criticism from doctors and industry experts who argue it prioritizes cost-cutting over patient care. ▼

The article also explores the challenges of holding EviCore accountable and the broader issue of prior authorization in healthcare. The financial structure of EviCore’s contracts incentivizes denials, raising concerns about objectivity in medical necessity assessments.


Every day, patients across America crack open envelopes with bad news. Yet another health insurer has decided not to pay for a treatment that their doctor has recommended. Sometimes it’s a no for an MRI for a high school wrestler with a strained back. Sometimes for a cancer procedure that will help a grandmother with a throat tumor. Sometimes for a heart scan for a truck driver feeling short of breath.

But the insurance companies don’t always make these decisions. Instead, they often outsource medical reviews to a largely hidden industry that makes money by turning down doctors’ requests for payments, known as prior authorizations. Call it the denials for dollars business.

The biggest player is a company called EviCore by Evernorth, which is hired by major American insurance companies and provides coverage to 100 million consumers — about 1 in 3 insured people. It is owned by the insurance giant Cigna.

Keep Reading

Armstrong, T. C. M. R. (2024, October 23). EviCore, the company helping U.S. health insurers deny coverage for treatments. ProPublica. https://www.propublica.org/article/evicore-health-insurance-denials-cigna-unitedhealthcare-aetna-prior-authorizations

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