Need advice

ldauph · June 1, 2004

Hi, I am in need of some advice for my brother in law. He is 25 yrs old and weighs 450lbs. He has Cigna and of course they have denied him. I told him he must appeal this. Can anyone with appeal expeirence guide me, so I can help him?

I have called Inamed and they told me that his surgeon would have to get in touch with them so they can work together on this appeal. He surgeon told him he does not get involved with appeals.I did tell him I think he needs to change doctors because this doctor does not have his best intrest in heart.

Anyway can anyone tell me what he will need to do on his own to appeal this?

La_madam · June 1, 2004

Hi My insurance company denied me too, the told me I had no co morbitites that go along with being obese. I weighed 265 at my surgery. So instead of fighting and appealing my insurance company which can take months even up to a year. I decided to go to Mexico and self pay. My surgeon in Mexico is trained by Inmed he does 4-5 lap bands a day and he is one of the top Lap Band surgeons in the country, he also offers financing throught Capital One. Has your brother ever considered going to Mexico and self paying? To me it was so worth it, then trying to fight my insurance company. I have been banded for 8 weeks today and I have lost 25 pounds. I know for a fact if I was stil ltrying to get coverage from my insurance company I would still be fighthing them today and I would not have lost 25 pounds. Just my thoughts and something for your brother to think about. My brother is 38 years old and weighs over 350 pounds. He is going to be having the surgery and he will be a self pay also. He lives with my husband, kids and I and he has been following my post op and is very excited for me as well as himself.

Michelle

Alexandra · June 1, 2004

Hi Laura,

Does your brother-in-law live in New Jersey? Does he work for a small company? If so, he's in luck. In any event, though, the place to start is with his contract. He clearly wasn't denied for medical reasons, so the question is why was he denied? There's no "of course" about it--he suffers from a medical condition and his doctor could easily make the case that surgery is an appropriate treatment for it.

Certainly the first step is to find a doctor who agrees with him. He can't possibly get insurance approval if his doctor doesn't believe surgery will help. If the doctor does believe it will help but just doesn't want to get involved, he can handle the appeals himself. My surgeon's office had no faith I could get my denial overturned, but I did and was ultimately banded at my carrier's expense.

ldauph · June 1, 2004

Hi Alex, Yes he does live in NJ although he does not work for a small company, he works for a well known company.

I think his doc feels he needs this done but he just does not want to get cought up in all the paper work.

Alex can you please let me know how you started the process of the appeal. Was it you just writing a letter ect?

I was banded in Aug I am down 62lbs, slow but I really feel this is the way for him to go.

By the way Alex.. do you also have cigna?

Alexandra · June 1, 2004

Hi Laura,

If your brother's company is large enough, they likely have a self-funded plan that is administered by Cigna. That means someone at the company made a lot of the decisions about what would be covered by the company plan. The State of New Jersey has guidelines and mandates that all insurance plans must meet, but it is permitted for self-funded plans to make a lot of their own decisions. If it is a self-funded plan, his first plan of action would be to appeal the decision within his own company. To do that he'd start at the human resources department. There has to be a procedure for appealing healthcare decisions made by the company plan, and he should find out what it is and follow it exactly.

Key to his appeal will be knowing why he was denied. His next step will depend on the answer. In my case, I was denied solely because Aetna felt the band was still experimental. So that's the point I argued, and eventually won on. They were not saying that the treatment was unnecessary, or that it wasn't covered by my contract, or that I didn't qualify for WLS, or any one of a million other reasons people get denied.

So why was he denied? What did the letter say, exactly?

ldauph · June 2, 2004

Alex, I think they gave a few different reasons.. one of them being experimental.. another was he was not on a supervised diet. I told him to call Cigna to find out the exact reason for denial. I also think the insurance company has guidelines that the doctor does not, one of them being to see a shrink. I told him to make an appointment for one now and to also start a file and document evrything from this day forward.

I will get back to you once he calls Cigna. Thanks for your replys.. I want to help him I just don't know exactly how. My insurance Co. approved me within a weeks time.

Alexandra · June 2, 2004

Laura, it's definitely not a lost cause. Tell your BIL to be patient and just take it step by step.

We can understand why insurers want to be very sure about the patients they pay thousands of dollars for. Making sure the patient is a qualified candidate and a good risk for surgical success is perfectly within their rights. Asking for evidence of a supervised attempt at weight loss is pretty much standard procedure.

The letter of denial has to be specific as to the reason for denial. If there are two reasons given those are the only things he needs to address in his appeals; think of them as marching orders. He has a right to clear communications from the insurer and to know what is missing from his file. You're absolutely right to tell him to document everything, and keep copies because he'll probably have to provide paperwork more than once.

With regard to the "experimental" label, Inamed can provide studies and material to counter that position. The doctor has no role in fighting that issue. But first things first: The first step is making sure he meets the medical criteria for weight-loss surgery.

ldauph · June 2, 2004

Again Alex, thanks for your replys.. I will tell him everything you have told me , and hope he follows through.. he is not very aggressive and is taking the denial point blank. He does not realize that he has rights and can fight.. I cannot do this for him , I can only help.

June 3, 2004

I have cigna and was denied a few weeks ago, now they are even refusing to pay for my consult that I had with the surgeon. I called them before I even went to the dr to see if they covered the band they told me yes, then I get a denial letter and a statement saying that wls isn't covered with my plan. I told them that I had spoke to several people at cigna and they looked at my plan and they had told me it was covered. I have heard so many negative things about cigna, like they will require you to go on a year supervised diet and they still not cover the surgery after you have done every thing that they want you to do. I am taking out a loan and will be a self pay. Good luck, but I just felt like I was fighting a battle that I wouldn't win.