Walter Lindstrom

This may have been discussed before but for anyone covered by CIGNA or one of its affiliated companies, they have abandoned their prior formal requirement of a specific duration (e.g. 3 months) in favor of this language: • A statement from a physician/physician’s assistant/nurse practitioner/registered dietician (i.e., other than the requesting surgeon) that the individual has failed previous attempts to achieve and maintain weight loss by medical management. This is the old language: • Medical management including evidence of active participation within the last 12 months in a weight-management program that is supervised either by a physician/physician’s assistant/nurse practitioner or a registered dietician for a minimum of three consecutive months ((i.e., ≥ 89 days). The weight-management program must include monthly documentation of ALL of the following components:  weight  current dietary program  physical activity (e.g., exercise program) Programs such as Weight Watchers®, Jenny Craig® and Optifast® are acceptable alternatives if done in conjunction with the supervision of a physician/physician’s assistant/nurse practitioner or registered dietician and detailed documentation of participation is available for review. However, physician-supervised programs consisting exclusively of pharmacological management are not sufficient to meet this requirement. Anyone covered by CIGNA now and going through a mandatory weight loss program under the old medical policy should request their surgeon/bariatric program to submit their request for approval NOW and not wait to finish the supervised diet. You might get some push-back from crusty bariatric practices or surgeons, but hopefully they will help you. The new policy is more favorable to patients, and because it is the medical policy in effect for anyone having surgery after October 9th, we take the position this is the operative medical policy - NOT the policy at a patient's "starting point". Call us at 1-877-992-7732 if you have questions about this or are in need of any information about what you need to do if you have been denied by your insurer - whether it is CIGNA or any other payer. Good luck to all! CIGNA medical policy effective October 9 2018.pdf

My apologies if "cross-posting" here is bad form - - just wanted to share a Halloween Blog that's very relevant to the season!

The ghouls and goblins don't just knock on your door yelling "Trick Or Treat"! They sometimes reside in the so-called "Customer Service" departments of health insurers, proving on a daily basis that they are not interested in their Customers and not usually capable of providing Service. We thought some of these stories, and we have oodles of them, made for an appropriately ghastly Halloween blog. Make sure you read all the way to the end so you can see what the Devil has in store for some of these folks in the insurance industry! "I don't have to give you any information about your appeal!" While this particular horror story involved an Aetna appeal years ago, problems like this happen all the time and we still can substitute the name of nearly every other major insurer for Aetna and have a similar tale to tell. Kelley was following up on an appeal we filed and was requesting confirmation that things were in process and inquiring about the status. The "Customer Service" person simply refused to provide any information despite confirming were the appealing patient's representative. So what......she just wasn't going to give any information to our office. Many reading this will know how incredibly nice Kelley is. If you don't know her then you can be certain her reputation for patience in matters like this is beyond dispute. Since this representative obviously wasn't going to budge Kelley calmly requested to speak to a supervisor. That's when things got interesting. The representative refused to transfer the call, stating the issue "did not rise to the level of involving a manager." A full thirty minutes later, after repeatedly demanding to speak with a supervisor and ultimately threatening to file a complaint with the Massachusetts Department of Insurance, Kelley was finally transferred to a Supervisor's voicemail, who got an earful of "message" from our office concerning what occurred. Kelley suggested the Supervisor listen to the recording of her exchange with the service representative because (don't forget) "this call may be recorded for quality assurance purposes." When the Supervisor called Kelley back she profusely apologized and confirmed the customer service personnel are required to transfer the member to a supervisor immediately upon request and that the representative was way out of line. The happy ending to the story is ultimately that Aetna approved the RNY gastric bypass that was the subject of our appeal! "I'm sorry but you don't have any right to appeal or obtain an IRO of this denial." There are some insurers who try to eliminate patient rights to appeal, especially appeals occurring before the surgery takes place. Some denials are labeled as coming from "courtesy reviews" with no appeals available. (I personally find it interesting they use the term "courtesy review" when they rarely do much of a "review" and hardly ever show any "courtesy" . . . but I digress. . . .) BCBS of Alabama is among a number of payers who sometimes try to bar appeals. It is very rare that appeals are not available prior to having surgery so don't just accept their statements as being true. We know when they are playing games and most of the time companies (like BCBS of Alabama) end up processing the appeal and when (shock of shocks) they tell us the member appeal was denied, we request an "external review." BCBS of Alabama, of course, has an unusually high level of incompetence so we should not have been shocked their response was that the member actually did not have external review available because the denial we received resulted from (you guessed it) a "courtesy review." Unbelievable! Enter Kelley (you'd think these companies would know better) who spoke to 2 different Supervisors about the situation, each of whom provided her with different (yet both still INCORRECT) stories about the nature of the member's rights. After spending one hour and 10 minutes on the phone Kelley was finally transferred to an "Operations Manager" who was truly horrified at what occurred. She immediately initiated an expedited IRO request and 7 days later our client was approved! When the dust cleared Kelley and the Operations Manager had a conversation and she again apologized for all the misinformation which was conveyed and assured us that they were using this case as a "teaching example" for their customer service personnel. "You didn't think that just because we APPROVED your surgery after your appeal we're actually going to PAY for it too, did you?!?" It can be truly horrifying for the physician and facility to not get paid after successfully getting an approval. Worse still are patients like us who fear getting HUGE bills even though we thought everything was settled after "winning" a pre-surgery appeal. This can happen, usually when the maze of insurance company Departments fail to update their systems to show things were approved. We sometimes need to go back to a payer, even after a successful appeal, and re-start the battle. It can time time, patience and knowledge to successfully navigate the insurer's system to get this fixed. Fortunately every time this happens we have gotten these claim denials resolved and re-processed for payment before the providers and patients turn into angry villagers storming Frankenstein's castle to chase these Monsters for the payment they are due. So as I wish everyone a safe and happy Halloween, I offer special greetings (and a warning) to insurance company executives and their customer service representatives who seemingly delight in making patients and providers miserable. They need to stop now. A number of years ago, at the Obesity Action Coalition's first Your Weight Matters conference, my costume included a button warning those in the insurance industry who do not change their ways. . .Hopefully they listen! HAPPY HALLOWEEN!!

I was unable to locate specific guidelines for the BC Complete Medicaid program dealing with bariatric surgery. I don't believe they have a separate criteria but I may be wrong on that; however here are their guidelines for other plans. I've included a LINK and the PDF. Good luck! Michigan BCBS Bariatric Medical Policy I've also attached the PDF file in case the link doesn't work. BCBS Michigan Guidelines.pdf

Best of luck to you as you get closer to receiving a decision from Anthem. I've written on this very painful topic in the past - here is the link in case it helps! https://wlsappeals.com/2142/walters_bariatric_surgery_blog/gained-weight-pre-op-diet-now-what/

It won't make you feel any better but I will tell you this happens ALL THE TIME with many payers - not just CIGNA (although we've had more than our share of battles with them). It is infuriating when you jump through all these hoops (most of which are "baloney" or another "B" word!) only to be told "no" at the end. Sometimes the "no" is more of a clerical issue that can be easily dealt with - other times it is much more involved. CIGNA just updated its medical policy and that change very well may have complicated how your preauthorization request was handled. (I've attached a copy of the updated version for you to look at. In many ways it is more "patient-friendly" but I'll bet your case was reviewed under a more restrictive medical policy.) You do have appeal rights available now so I recommend you give us a call so we can find out more about why they said no and give some guidance about your various options. Hope this helps. CIGNA medical policy effective October 9 2018.pdf

First off, congrats on taking this giant step toward improving your health! I wish you the best in your journey. This is a fabulous and supportive community who will help you. Hopefully I can give you some important guidance. Your statement about bariatric surgery being excluded on the one hand, but you having the chance to establish "medical necessity" on the other hand really are somewhat contradictory so be very, very sure you have the coverage you think you have. It's awful when folks go through the full process only to find out at the end they did not have coverage in the first place. Have you actually obtained a copy of your Florida Blue coverage certificate (Sometimes called a Summary Plan Description)? Remember you need to look at the full booklet, not just the Summary of Benefits and Coverage that's usually only a few pages long. If the exclusion includes words like "unless medically necessary" or similar, you should be OK. But you REALLY NEED to confirm coverage for your surgery exists - don't take the word of the "customer service" morons who answer their phones at Florida Blue. They aren't interested in customers, nor do they provide much service. I've attached their Medical Policy which was just revised in July. I'm also attaching their Medical Necessity checklist. Hope they help. Last quick thought: don't rely on your PCP writing a letter by itself. Be sure to have medical records which establish your OSA diagnosis and start gathering your proof of non-surgical weight loss efforts because no doubt you'll need those sooner rather than later. Good luck! Bariatric Surgery CMN.doc mcg.pdf

BCBS MA does not have a specific 6-month supervised weight loss requirement. The link for their most recently updated medical policies is http://www.bluecrossma.com/common/en_US/medical_policies/medcat.htm . Under O you'll see Obesity Surgery (medical policy 379). I've also attached it. Hope this helps. Good luck. 379 Medical and Surgical Management of Obesity including Anorexiants prn (1).pdf

You don't have to live with terrible acid reflux just because your insurer says so! Fighting Insurers Who Deny Anti-Reflux Surgery After Sleeve Gastrectomy

I've attached a PDF of the latest UHC medical policy which does include a 6-month diet requirement: "The individual must also meet the following criteria: o Documentation of a motivated attempt of weight loss through a structured diet program, prior to bariatric surgery, which includes physician or other health care provider notes and/or diet or weight loss logs from a structured weight loss program for a minimum of 6 months;" I've been preaching against these diet programs for many, many years ( "June Gloom" & Bariatric Surgery Insurance Denials ) because there is no evidence showing these delays improve outcomes. They are especially dangerous to start towards the end of the year because of the risk that coverage might change after January 1st. Good luck and I hope this information helps any UHC folks out there! Regards, Walter Lindstrom UHC bariatric-surgery.pdf

Whether you’re reading this as the patient who needs bariatric surgery, someone who loves that patient, or the provider committed to caring for the patient, there are at least three important lessons coming out of this experience that should be taken away for future benefit. Three takeaways coming from beating CIGNA and winning another bariatric surgery appeal

Too often we see this at this time of year: a person who had coverage in January finds out he or she lost it when their employer renewed its insurance with a new company. While this may happen at the end of December for many plans, there are one helluva lot of employee plans which changed in July. Please CLICK HERE to learn more about this

Sadly this has been going on for a long time. Here is a link regarding a similar situation (not Geisinger but with Aetna) which may help: https://wlsappeals.com/2142/walters_bariatric_surgery_blog/gained-weight-pre-op-diet-now-what/

Last year at this time I posted this Blog about why June is such an important month for patients seeking surgery. http://bit.ly/1SUlolN I thought it was worth bringing to folks' attention. Here's a snippet: "By waiting you are RISKING that you might be one of the unfortunate ones whose failure to plan well in June caused them terrible Gloom at the end of the year, even though they thought – and their bariatric program thought – jumping the silly hoops and playing by the insurance plan’s rules was the right thing to do. So if your bariatric program is talking about having you wait and jump through more hoops show them this post and get them to re-think that plan. It could be a terrible but avoidable mistake." I hope this helps anyone who is being told by their bariatric program that it's better to wait to complete "the diet" before getting submitted to insurance. Sadly, that's usually not the case but you probably won't know until the end of the year. Good luck to all!

<<It is not possible to get this in writing (apparently) and the documenation is unpublished to the insured individual on the MYUHC website.>> WRONG - It is possible but geez . . . why would an insurance company want to make things easy for their members, right? The UHC medical policies (Hint: like MANY other insurance companies) have their medical policies buried in the "provider" section of their website(s), not the member portion. Here is a link which should (if I did it right) get you to a pdf with UHC's complete medical policy: http://bit.ly/1vIO2Ht (If I didn't do this right feel free to email me directly) Hope that helps!

I'm not sure why they would tell you that unless there is a provision in your particular insurance plan language because a 5 year history of morbid obesity is NOT part of BCBSNC's medical policy which I've linked here (or at least tried to link). http://bit.ly/1u1GIpH You cannot give what you don't have (i.e., a 5 year history) so they should submit the records which are available because with a BMI of 44.4 it doesn't seem like medical necessity should be a real issue (but of course that's for the surgeon to determine). Hope that helps.

We have the answer to your question on our wlsappeals.com website. Here is the link: http://wlsappeals.com/common-bariatric-denials/ Hope that helps! Good luck!