You just left your oncologist’s office. You’re terrified. They found something suspicious on your scan, maybe it’s a new mass, maybe your tumor markers are rising. Your doctor wants a PET scan immediately to see if the cancer has spread. You need answers now.
But first, your case gets shipped off to some faceless reviewer at a company you didn’t choose and probably can’t even pronounce. This person has never met you, knows nothing about your medical history, and couldn’t care less about the clinical notes your doctor spent time writing.
Welcome to healthcare, brought to you by EviCore.
Who Is Evil EviCore?
EviCore is a third-party “benefits management” company owned by Cigna’s parent, Evernorth. Sounds harmless, right? It’s not. It’s the company that Aetna, Cigna, UnitedHealthcare, Oscar, and even some Medicaid MCO plans outsource to when they don’t want to deal with prior authorizations themselves.
They act as the gatekeepers for tests and procedures that your physician has already deemed medically necessary. They control the portal. They control the phone lines. And most importantly, they control the delay.
Think of them like customer service for denial letters, except instead of “your call may be recorded,” it’s your life on hold.
How Do They Decide? Spoiler: You’re Not Involved.
According to investigative reports from CNN and ProPublica, EviCore’s denial system is largely algorithm-driven. Let that sink in. A computer program decides whether your PET scan to check if your cancer has spread gets approved. Because nothing says “quality healthcare” like letting a machine with zero medical training decide if your oncology imaging is worth it.
And if your case does make it to a medical reviewer? Surprise, they’re often given a set time limit to review complex cancer cases and expected to stick closely to restrictive scripts and insurance “guidelines” that aren’t even based on current oncology standards.
Physicians interviewed said they were pressured to deny cases. One internal reviewer said he was scolded like a child for approving too many cases. Another physician couldn’t even review imaging requests because he wasn’t trained in radiology, but was expected to approve or deny cancer scans anyway.
Real People. Real Delays. Real Damage.
One man with pancreatic cancer had his PET scan delayed due to an EviCore denial. A woman with a breast cancer history was denied follow-up imaging until her symptoms worsened. Another patient’s bone scan was rejected three times while their oncologist stood on the sidelines not being able to do a damn thing.
You think these are minor issues? They are not. This is a business model. Every denial saves money. Every delay pushes cost onto someone else usually you, the patient, or the emergency department when you finally show up in crisis.
And let’s be clear: it’s not just patients who are suffering. It’s every office staff member who has to log into the portal three times, fax pathology reports no one reads, and waste enormous amount of time to get services approved.
This isn’t utilization management. This is denial outsourcing with a clinical accent.
From the Front Lines: What Healthcare Workers See.
Healthcare workers describe the EviCore system as deliberately frustrating. The portal is clunky and unreliable. Requirements change without notice. Staff upload oncology reports, pathology results, imaging studies, hit submit, and cross their fingers the algorithm doesn’t reject everything outright. (Provider portal for Evicore sucks, trust me.)
The denials come back vague, “not medically necessary” with zero clinical explanation for why a cancer patient’s PET scan got tossed. Appeals get denied. Maybe they approve it after the third appeal, but by that point, your patient is a wreck, the cancer may have spread, or they just give up.
Medical assistants and office managers burn out from the constant battles. Oncologists lose their minds wondering, “Why was this procedure denied?”
The answer is obvious: EviCore is in business with the insurance companies and it’s to their mutual benefit to deny services that could hurt their corporate dollars.
What Needs to Change?
If you’re an oncologist, and EviCore is determining whether you can move forward with cancer care, you’re not practicing medicine. You’re waiting for permission to practice medicine on patients who could be dying.
If a physician cannot decide when their patient needs a test, then what exactly is their role? Are they medical providers or just data entry clerks?
If you’re a cancer patient, and you’ve been denied a scan your oncologist ordered, know this: it’s not your doctor’s fault. This a system that profits from slowing down your medical treatment.
So here’s what needs to happen:
- Transparency in how third-party reviewers operate, especially for cancer cases.
- Oversight into algorithmic denials, no computer should decide cancer care.
- Accountability when delays cause harm, real consequences, not just “oops.”
- Oncologists, not portal reviewers, are making the final call on cancer imaging.
You can call it cost control. You can dress it up in clinical language. But if EviCore is the one making decisions about your care, let’s call it what it really is: a denial machine, built for profit, gambling with patient lives.
Healthcare should be about access, especially when you’re fighting for your life. Not algorithms deciding if your tumor is worth investigating.
Your physician should not need permission to treat you from an online portal system.
Your health should not be delayed by someone who has never met you.
And your life should not be part of a cost-saving strategy.
Do better. Be better.
Philip, Agnel. “Not Medically Necessary.” ProPublica, Oct. 16, 2024.
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