EviCore, a subsidiary of Cigna, uses an algorithm dubbed "the dial" to influence prior authorization decisions for insurers covering over 100 million Americans. Internal data reveals the company denied 20% of requests in Arkansas, nearly triple Medicare Advantage's 7% rate. Barbara McAneny, former AMA president, criticized the system, calling it "profitable denials."

EviCore's algorithm automatically approves requests but escalates others to human reviewers. Former employees confirmed the dial adjusts review thresholds to prioritize denials, with one executive stating, "That's the game we would play." The system sends requests scoring below 95% for manual review, increasing denial likelihood. 3-to-1 ROI promises incentivize insurers to cut costs, as EviCore profits from reduced payouts.

Medical guidelines, marketed as evidence-based, face scrutiny for being outdated and rigid. A former employee noted executives targeted specific companies for tighter oversight. While EviCore claims its AI accelerates approvals, critics argue the dial manipulates outcomes. Competitors like Carelon Medical Benefits Management face similar allegations, highlighting systemic issues in prior authorization practices.

The controversy underscores tensions between cost control and patient care. EviCore's practices, defended as quality improvements, reveal how algorithmic adjustments can prioritize profits over medical necessity. As healthcare systems grapple with rising costs, the role of profit-driven denials remains a critical debate.