Wellfleet Insurance Company - VT Act 140 Prior Authorization Compliance Attestation 2026

Questions:

The below questions apply to health plans as defined in 18 V.S.A. 9418(a)(8) (including third party administrators, to the extent permitted under federal law):

1. Has the health plan reviewed the list of medical procedures and medical tests for which it requires prior authorization (PA) at least once during the proceeding plan year and eliminated the PA requirements for procedures and tests for which such a requirement is no longer justified or for which requests are routinely approved with such frequency as to demonstrate that the PA requirement does not promote health care quality or reduce health care spending to a degree sufficient to justify the administrative costs to the plan?

Wellfleet Insurance Company utilizes Cigna to perform all prior authorizations and utilization management functions for our members. As such, the answers below were provided by Cigna.

Cigna response: Yes, Cigna's Precertification Committee is charged with reviewing the Master Precertification List annually and/or more frequently to determine the addition or removal of codes for non-delegated services.

a. What is the health plan’s timeline for reviewing and eliminating prior authorization requirements? In answering this question, please provide the dates for the two most recent review cycles.

Cigna response: Code review occurs at least annually. The two most recent reviews took place in May 2025 and February 2026.

b. Does the health plan ever add/eliminate PA requirements during a plan year (as opposed to between plan years)? Please explain.

Cigna response: Yes, the Precertification Team meets monthly to conduct routine activities, including reviewing for the release of new services/codes to determine if code(s) relating to services have been retired from use/replaced by another service code(s), or a new therapy becomes available.

c. What are the standards used by the health plan to evaluate PA requirements as outlined in 18 V.S.A. § 9418b(h) (including the thresholds the health plan considers in looking for routinely approved PAs, how the health plan determines whether PAs are promoting health care quality or reducing health care spending to a degree sufficient to justify the administrative costs to the plan)?

Cigna response: For inclusion in the prior authorization list the following factors are considered:

i. Experimental/Investigational/Unproven Service (Non-Quantitative)

Wellfleet Insurance Company - VT Act 140 Prior Authorization Compliance Attestation 2026

ii. Service is/may be excluded from benefit plans (Non-Quantitative)

iii. Serious Safety Risk (Non-Quantitative)

iv. Significant variation in evidence-based care (Non-Quantitative)

v. Fraud/Waste/Abuse (Non-Quantitative)

vi. Estimated Average Cost (Non-Quantitative)

vii. Return on investment (Non-Quantitative)

Thresholds for inclusion by factor type are as follows:

• Non-Quantitative Factors: Any one or combination of the factors identified as non-quantitative may be considered for application of prior authorization.

• Quantitative Factors: Both factors (Estimated Average Cost and Return on Investment (ROI) must be met for application of prior authorization.

  d. Does the health plan take into account the administrative burden of PAs on health care providers and patients and whether the administrative barriers to submit PAs may inhibit access to medically necessary care? Please explain.

Cigna response:

2. What medical procedures and tests had PA requirements eliminated or added during the preceding plan year and what was the rationale for changing those requirements?

Cigna response:

3. What are the ten most requested PAs for both medical PAs and prescription drug PAs (20 total) during the preceding plan year? For each of the 20 PAs, please provide the number of PAs requested and approval rate for each PA (PAs in this list may overlap with eliminated PAs identified in question 2).

Medical Prior Authorizations

Procedure	Procedure Description	Total	Approved	Denied	Approval Rate
73721	MRI Lower Extremity, any joint; without contrast material(s)	75	70	5	93.3%
Rehabilitation Services	Rehabilitation Services	20	9	11	45.0%
73221	MRI Upper Extremity, any joint; without contrast material(s)	19	18	1	94.7%
MH Inpatient Stay	MH Inpatient Stay	15	14	1	93.3%
73718	MRI Lower Extremity, other than joint; without contrast material(s)	14	14	0	100.0%
72148	MRI Lumbar Spine, (spinal canal and contents); without contrast material	11	8	3	72.7%
70551	MRI BRAIN (head); without contrast	8	8	0	100.0%
73222	MRI Upper Extremity, any joint; with contrast material(s)	8	8	0	100.0%
70486	CT MAXILLOFACIAL area, without contrast material	6	5	1	83.3%
70553	MRI BRAIN (head); with and without contrast	6	6	0	100.0%

Wellfleet Insurance Company - VT Act 140 Prior Authorization Compliance Attestation 2026

Pharmacy Prior Authorizations

4. What percentage of urgent and non-urgent PA requests are granted because processing time exceeded the statutory timeframes established under 18 V.S.A. § 9418b(g)(4)?

Cigna Response: