oscarel

Yes, he did the same with the group I was with. And boy , did I make the best of it. I stopped at KFC on the way home and got a 2 piece meal with extra crispy. I'm not an extra crispy guy, but boy did it taste good. Then about 2hrs later the family went to Abuelo's Mexican Restaurant in Plano and had dinner. I'm satisfied that the wait and sugery are now behind me and I can get on to a much better and healthier life. Oscar

Is this the doctor he's referring to? Professor Paul O

I've heard stories of people committing suicide after having bariatric surgery. They think that losing weight will make all their problems go away and of course they don't. So I would think this may be the insurance company's way of saying they checked before approving the surgery. The eval I had about 200 of the 300 questions were about my mental state and about being suicidal.

I was approved with only 2 years of medical history, which I'm glad because I too only had about 4 years worth. Also the only thing my PCP provided was a small statement on my physical that mentioned I was getting lapband surgery for obesity, no long letter needed. Make sure to call Cigna a couple of days after the paperwork is submitted and see if they have it. When I called they had received it but hadn't sent it to a nurse yet for approval. The guy I spoke with was very nice and he sent it on, 4 days later I was approved. Good luck. Oscar

Cigna has revised their coverage terms for bariatric surgery as of 5/15/08. They now require 24 months proof of obesity. Also looks like they now accept Weight Watcher if done under supervision of a doctor. Optifast® are acceptable alternatives if done in conjunction with physician supervision and detailed documentation of participation is available for review. For individuals with long-standing, morbid obesity, participation in a program within the last five years is sufficient if reasonable attendance in the weight-management program over an extended period of time of at least six months can be demonstrated. However, physiciansupervised programs consisting exclusively of pharmacological management are not sufficient to meet this requirement. • Evaluation by a multidisciplinary team within the previous 12 months which includes the following: an evaluation by a surgeon qualified to do bariatric surgery recommending surgical treatment a separate medical evaluation recommending bariatric surgery clearance for surgery by a mental health provider a nutritional evaluation by a physician or registered dietician Bariatric Surgery Procedures: When the specific medical necessity criteria noted above for bariatric surgery have been met, CIGNA HealthCare covers ANY of the following bariatric surgery procedures: • vertical banded gastroplasty • Roux-en-Y gastric bypass • adjustable silicone gastric banding (e.g., LAP-BAND®, REALIZE™ ) • biliopancreatic diversion with duodenal switch (BPD/DS) for individuals with a BMI (Body Mass Index) > 50 CIGNA HealthCare covers adjustment of a silicone gastric banding as medically necessary to control the rate of weight loss and/or treat symptoms secondary to gastric restriction following a medically necessary adjustable silicone gastric banding procedure.

Cigna will not precertify until you've met their requirements. They also do not accept your own personal logs, you must visit a doctor and have your vitals noted. I posted their new requirements here http://www.lapbandtalk.com/f8/cigna-revised-coverage-position-5-15-08-a-63835/ Note that they update this every year, so May of 2009 this may change. I guess I was one of the fortunate ones, it only took 1 week for them to approve me. Oscar

Here's what Cigna requires as of 5/08 and from what I can tell they update it in May of each year so keep that in mind if you go beyond next May submit you paperwork: http://www.lapbandtalk.com/f8/cigna-revised-coverage-position-5-15-08-a-63835/ I would think your weight loss center or doctor would be the best to answer these questions since they work with this on a daily basis. Insurance is not the same for everyone, even with the same insurance company due to the way the policies are contracted. They may not be the same with 2 people from the same company either. Follow their requirements and call them to verify if they have the paperwork once you do submit, and appeal or escalate when required.

Is this you insurance requesting this or the weight loss center?

kfgates, if you're going the insurance route did you ask them if it's covered before starting all this? If you're going to be self pay then there's probably no reason for the 6 month diet. Oscar

Have they given you a reason for denying?

So it wasn't that bad! WLS submitted paperwork last Thursday, I called Cigna on Tuesday morning to see if they had received the paperwork. The person I spoke to said it was received and he submitted it to have a nurse review it and he said I should have the results by early next week. We'll today I got a call from the WLS saying I was approved! My BMI is 46% and I have no co-morbids. Also I nor my pcp didn't have to submit an actual letter for this being medically required. I had a physical back in January and in it my PCP stated that I was going to have Lapband surgery to help with being obese. So I believe it's all in who looks at your paperwork and what kinda mood their in. Good luck to everyone. Now it's time to get that magic date!!

Hi Auntlucy, I'd be interested. I haven't been banded yet, but I should be in the next month. Oscar

Trish, I wouldn't be afraid of you PCP, they work for you. Is you hospital submitting the paperwork for insurance approval? Why don't you ask them? So far the only thing that I've had to get from my PCP was a letter stating I was OK physically to have the surgery. You may need to have a physical for them to write this letter, and I believe it's required for approval. You probably should've started this process a month or so ago... Oscar

So far Cigna has been very upfront with me. When I called to inquire about bariatric surgery they emailed me their position on it, CIGNA HealthCare Coverage Position 0051. I also found this from cigna.com by searching for bariatric, it was the 3rd hit. And looking at the dates on this it's been in effect since 5/04. It also sounds like your surgeon's office should have some idea at to what Cigna requires, I would think they would have checked whether you were covered or not before you started. Now this is coming from my limited experience, I'm using a bariatric surgery clinic and I've only had to call them twice, initial call and one about them covering the psych exam. And as mentioned earlier your employer has a LOT of input on what's covered as they are the one's really paying for it.

Cigna's Coverage Position clearly states you must have >40 BMI for over 12 months. The document they referenced me to was mm_0051_coveragepositioncriteria_bariatric_surgery.pdf. Here's the first part of that document. CIGNA HealthCare covers bariatric surgery using a covered procedure outlined below as medically necessary when ALL of the following criteria are met: • The individual is ≥ 18 years of age or has reached full expected skeletal growth AND has evidence of one of the following: BMI (Body Mass Index) ≥ 40 for at least the previous 12 months. BMI (Body Mass Index) 35–39.9 for at least the previous 12 months with at least one clinically significant comorbidity, such as a serious cardiopulmonary problem, Type 2 diabetes, hypertension, coronary artery disease, or pulmonary hypertension that has failed to respond adequately to appropriate medical management. • Active participation within the last two years in one physician-directed weight-management program for a minimum of six months without significant gaps. The weight-management program must include monthly documentation of ALL of the following components: Vital signs, including weight Current dietary program Physical activity (i.e., exercise program) Behavioral interventions to reinforce healthy eating and exercise habits Consideration of pharmacotherapy with U.S. food and Drug Administration (FDA)- approved weight-loss drugs, if appropriate For individuals with lifelong, morbid obesity, participation in a program within the last five years is sufficient if documentation of six months is available and reasonable compliance with the weightmanagement program over an extended period of time can be demonstrated. However, diet programs/plans alone, such as Weight Watchers®, Jenny Craig® and similar plans, are not considered physician-directed weight-management programs and do not meet this requirement. Similarly, physician-directed programs consisting exclusively of pharmacological management are not sufficient to meet this requirement.

Carrie, I just had my psych exam denied by Cigna as well. But I called them and they told me that I actually have "mental health" insurance through a different company. Not only does the mental health insurance cover it, but the copay was also $10 cheaper. I had to be pre-approved and the lady I spoke with back-dated the approval. So you may want to check and see if this is the case for you too! On my insurance card there's a different number listed on the back at the bottom that says MH/SA. Good luck with your surgery approval I'm 2 months away from that headache.

Is that lifetime out of pocket or lifetime benefits? I don't think it's as easy as giving a figure because the charges will be different from patient to patient and insurance to insurance.

Most retail credit cards do accrue interest, Best Buy, Home Depot. I've never had a normal credit card that charged accrued interest. You should always read the terms and conditions before using them.

If your credit is good why not open a credit card account that has 0% interest rate? The Disney Visa from Chase is offering 0% for 12 months.

I asked AIGB/TrueResults in Richardson the question of approximately what they would charge my insurance, Cigna, and they of course couldn't give me a number. I would guess it will not be what they would charge a cash paying customer. What normally happens is they "negotiate" the rate and you will pay 10% of the negotiated rate. I'm in the six month diet period and the first visit just cleared insurance. AIGB submitted $300 but the negotiated rate was $100.

That's what I thought, but AIGB seems to believe they need 5 years. I have my psych exam scheduled with my next visit. The receptionist said it was 2hrs and there was a 350 question exam!! Boy, I'm not looking forward to that. Luckily they didn't push/question me about the sleep test. 4 more months!!

Thank you both for the comments. I will definately be looking into this more before the surgery. One more question. Did ether of you have to provide more than 12 months proof of obesity? I've got the document provided by Cigna "mm_0051_coveragepositioncriteria_bariatric_surgery.pdf" that states "BMI (Body Mass Index) ≥ 40 for at least the previous 12 months" but AIGB insists they need 5 years. This isn't that big of a deal, just wondering.

Ok, for the 4 doctors that show up on Trueresults.com for the Dallas office, Dr. Marsden and Dr. Fox show up for Cigna. So I guess I'll have to contact AIGB again tomorrow and inquire about it again.

Thanks MirandaK for responding. You know that's the one thing I didn't check was to see if the doctor was in-network, I'll look that up now.