Need help figuring this out, please

[CSinTX 0]

I am trying to decipher this portion of Cigna's policy.

The first paragraph mentions the 6 month diet within last 2 years.

The second paragraph mentions 6 month participation in weight management program within the last 5 years.

Are they giving us 2 ways to meet the diet qualification?

Thanks for your time.

Cathy

Failure of medical management including evidence of active participation within the last two years in a weight-management program that is supervised either by a physician or a registered dietician for a minimum of six months without significant gaps. 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 or registered dietician 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, physician-supervised programs consisting exclusively of pharmacological management are not sufficient to meet this requirement.

[KateTheGreat 0]

The way I've interpreted Cigna's policy is that if you have a BMI OVER 40 you can do the diet thing within the last 5 years, otherwise if your BMI is 35-39.9 then it has to be within the last 2 years. Does that make sense?

I also have Cigna and am beginning my 6-month diet now.

[CSinTX 0]

I kinda gathered that as well since they said "morbid obesity" but they don't define what they consider morbid obesity BMI to be.

I am 1 month into my 6 month diet. Lets keep in touch since we are at the same time with the same insurance program.

I go for my second weigh in on Monday the 22th. On my first visit they ran every test possible and Cigna covered everything 90%. So far Cigna been great.

Cathy

[KateTheGreat 0]

I kinda gathered that as well since they said "morbid obesity" but they don't define what they consider morbid obesity BMI to be.

I am 1 month into my 6 month diet. Lets keep in touch since we are at the same time with the same insurance program.

I go for my second weigh in on Monday the 22th. On my first visit they ran every test possible and Cigna covered everything 90%. So far Cigna been great.

Cathy

Hehe, isn't that crazy, we're both Kathy's!! Okay...so maybe I'm not w/ a C, but still:)

Since we're both w/ Cigna and starting the same point, perhaps you can help me speculate (I over-analyze everything...hehe)! I've seen the doctor for illnesses and such over the last few months and I've been weighed and had my BP taken each time. I wonder if instead of having a separate piece of paper with each weight and stuff, if my doctor can include in his documentation just a summarization of the dates seen and my weights and BP, and if that would count towards my 6 months? Because then I'd be much farther along:thumbup:

[CSinTX 0]

Hi Kathy,

I am under the impression that your PCP would need to include in his notes what was discussed on those monthly visits. Such as what type of exercise you plan were doing or planning on doing and what diet you did or will be doing. Atkins, Weight Watchers, South Beach or reduced calorie, etc.

I have over 20 doctor visits spread out over the past 5 years with those exact discussions but none 6 months consecutive and most of them are older than 2 years. Because my BMI was not over 40 for any consecutive visit I plan to do the 6 month diet thing and then submit. After reading other posts it sounds like you get just a couple of changes to appeal if you get denied and I don't want to take any changes.

Have you asked the insurance person at your WLS clinic that question? I asked mine and she said we can submit but she did not think it would be approved. Besides it only cost me $15 each month so that is not a factor. Patience is not one of my virtues, but I'm working on it.

I over analyze everything as well, so we'll be a great team.

Cathy

[KateTheGreat 0]

I hear you...I am a very impatient person. I'll be talking to my PCP and WLS clinic tomorrow, so hopefully I'll know a little bit more to speculate on:)

[CSinTX 0]

Hi Kathy,

I just noticed you are from Iowa. I live in Texas but my daughter goes to ISU in Ames.

Good luck tomorrow and let me know what you find out.

Cathy

[KateTheGreat 0]

Oohh too bad she's not a Hawkeye fan:( lol!

I found the specific requirements on Cigna's website about bariatric surgery (I called and they pointed me to this location):

http://cigna.com/customer_care/healthcare_professional/coverage_positions/medical/mm_0051_coveragepositioncriteria_bariatric_surgery.pdf

:thumbup:

[KateTheGreat 0]

Alright, I had my appointment with my PCP and we were able to pull records for the last year or so where we've discussed my obesity, diet and exercise plans. The first two months have a 3 1/2 month gap, and there's one that has a two month gap, otherwise the rest are month-to-month. I have my consultation on Friday and a bunch of other things so I imagine they'll submit insurance on Friday since I do have 6 months worth. I'm crossing my fingers that it'll be enough!!!:scared2:

[CSinTX 0]

Hi Kathy,

I am so excited to hear that you'll be submitting your paperwork soon and hopefully you'll get your approval by the end of the month.

I go for my 2nd dietician appointment on Monday and plan to sit down with my insurance coordinator to see exactly what my PCP sent her.

Keep us updated on your progress and again congratulations.

Cathy

[KateTheGreat 0]

Hi Kathy,

I am so excited to hear that you'll be submitting your paperwork soon and hopefully you'll get your approval by the end of the month.

I go for my 2nd dietician appointment on Monday and plan to sit down with my insurance coordinator to see exactly what my PCP sent her.

Keep us updated on your progress and again congratulations.

Cathy

Oh, good!! That will be so exciting!!! Let me know how your appointment goes. Don't you have something going on tomorrow, too??