Kind Of Denied...but Not Really?

[tomato pie 15]

Received a letter today from Cigna saying, "We are unable to substantiate medical necessity for the requested services". And then "Please be aware this is not a denial". Um... Ok... then what is it? I do plan on calling them, but it's Saturday and have to wait till Monday. So, to ease my nerves, have any of you received a letter like this?

[honk 780]

No, never got a letter like this but what does your policy require for them to cover surgery? For example do you need to demonstrate that you have muliple comobidities or a specific amount over weight? If so did your PCP or surgeon document those requirements? Some have to show documentation that they have been overweight for 3 years. If the doctor does not send records supporting that the insurance will decline.

[245hot 7]

Received a letter today from Cigna saying' date=' "We are unable to substantiate medical necessity for the requested services". And then "Please be aware this is not a denial". Um... Ok... then what is it? I do plan on calling them, but it's Saturday and have to wait till Monday. So, to ease my nerves, have any of you received a letter like this?[/quote']

What's your bmi

[tomato pie 15]

No' date=' never got a letter like this but what does your policy require for them to cover surgery? For example do you need to demonstrate that you have muliple comobidities or a specific amount over weight? If so did your PCP or surgeon document those requirements? Some have to show documentation that they have been overweight for 3 years. If the doctor does not send records supporting that the insurance will decline.[/quote']

According to their website I meet/exceed all their stated requirements, I have no idea what exactly the doctor has documented or submitted.

[tomato pie 15]

My BMI is 44.

[JessiG1983 50]

Sounds to me like the insurance didn't get all required documentation. I wouldn't worry too much about it for now. Just call first thing Monday, find out if the issue is your doctors office, then whip them into shape (LOL).

[Sojourner 2,446]

Received a letter today from Cigna saying, "We are unable to substantiate medical necessity for the requested services". And then "Please be aware this is not a denial". Um... Ok... then what is it? I do plan on calling them, but it's Saturday and have to wait till Monday. So, to ease my nerves, have any of you received a letter like this?

Every practice usually has a specialist to deal with the insurance companies, so they are aware of the exact verbiage needed for approval. In my records, essentially for 18 months there were no records for my weight being recorded. I was advised by the insurance specialist to write a letter to be included with the rest of my medical documentation and 3 years worth of medical records to explain why this important piece of information was missing.

My primary care physician had much previous experience in medically supervising the required diets, and the verbiage in his letter of medical necessity also documented my history of being overweight and my weight related comorbidities.

With the medical professionals who know the needed verbiage and the insurance specialist, I was approved with the first request. My BMI was 38, but I had 4 weight related comorbidities.

Ask to speak with the insurance specialist at your doctor's office to determine what medical documentation may have been omitted.

Best wishes...

[tomato pie 15]

Finally got ahold of the right person at the insurance company. I wasn't kind of denied. I was as denied as you can get . She told me to call my surgeons office. I did and am now waiting for a return call...