So Upset.......please Need Advice And Input!

[ginger0429 0]

I was planning on introducing myself.... and so happy to tell everyone that my surgery date is set for Oct 8. I have done the six month supervised diet,all the preop tests everything that was required. I came home tonight and received a letter from Cigna stating at this time they do not feel there is medical necessity for this surgery and that I should send more documentation to support the necessity. I am 275 lbs 5'3,my BMI is 50 ....Really...my knees hurt,Im tired all the time,my back,feet hurt etc and oh yeah I want to live longer,be healthier,see my kids grow..Im so ready in every sense of the word for this.I have a bad feeling.I do not have diabetes or high blood pressure,so if a BMI of 50

being 275 lbs at 5'3 is not enough and not having any comorbitities (sp) Im not sure what I can do.I feel like Im going to have a fight on my hands.I mean the good news is it said this is not a denial letter,but I am just not sure what more I can send them to warrant the surgery. Please any advice is welcomed I wanna so bad join all of you on that loosers bench. I get so inspired and excited reading all of your stories on here.

[raerae39 8]

Do not give up. They may need proof that you have been obese for the last three or four years. Speak with your bariatric surgeon's office and see what their take is on it and maybe they can help. Are you pre diabetic? Hemoglobin A1C of 5.7 and up? That can help your cause, if so. Good luck to you.

[thesmilos 144]

I know someone who drank a coke before her fasting lab work so it would look like she was a diabetic. That's what ultimately led to her doctor approving her surgery. She was 5'4" and over 300 lbs and furious that she had to do that to get approval, but it worked for her.

Sorry you are having to deal with insurance. Perhaps your doctor could provide another letter explaining the rationale for the need for surgery. Good luck to you.

[Fun size 62]

In have read in more than a few places that CIGNA automatically declines the firsttime and you have to resubmit it then it will go through. Have you had a sleep study? Having a CPAP machine would count as a comorbidity. Your leg and back pain should count too. Not even a little high BP? What about cholesterol? That counts. do not give up!! You will get there.

[OneBigTeddyBear 18]

Have you been tested for sleep apnea?

[honeycomb822 3]

Hi Ginger,

Please do not get down, I exactly how you feel as I spent the last year arguing with my insurance company. Be determined and most importantly know that you surgeon will help you in any way possible. I have a top bariatric surgeon from Boston Mass. and even with her help it took this long. Here is a lsit of all I have been through so you can see how horible these companies can get:

• had lapband out 4/2011 because it infected and almost killed me
  
• 9/2011- Surgeon submitte for revision and we were denied because they wanted updated info.
  
• 12/2011-was denied because BMI was not high enough and I was not sick enough(truely this is the honest truth)
  
• 2/2012-denied again still not heavy enough(gain40 lbs. at this point)
  
• 4/2012-BMI finally right, new medical info. submitted was denied again..why the company never updated any info that ahd been sent. Denial based on info. fro, 9/2011
  
• 5/2012-had outside appeal and talked with lawyer
  
• 7/2012-re-submitted thing outside appeal wanted was denied again(this time because they again did not us new information and BC/BS even had infor. that was not mine in this denial
  
• 8/2012-Surgeon had enough called BC?BS and informed them their info. was not anywhere near correct...after this coversation..surgery was approved and done last Tuesday.
  

This no doubt the worst part but be strong and you will make it. Most importantly keep ALL information from the insurance company and the info. sent to them. By proving they were not being honest and doing their job they could no longer deny because I had all the info. to prove I meant all credentials they required. The icing on this cake is BC/BS refused to return the hospitals calls for approvals I had to fax them down today.

As you can see this last year was hell but like me you will come out on the other side, just do not quit. Determination ticks of the insurance companies and really will pay off. Hope this helps.

[Ready4success 380]

It wasn't an outright denial, so they're looking for info. As the previous posters said, get with your surgeon's insurance coordinator, and they should be able to tell you what can help your case. That's what they specialize in, getting insurance to pay. With a high BMI, even without co-morbidities, I'm sure there's something that can be used. Fatty liver disease? High cholesterol? Borderline diabetes? Joint pain? Back problems? Pre-hypertension? You have to get creative. Good Luck!

[Raven21 121]

Most good bariatric centers know which hoops they have to jump through for which insurances. Talk to the coordinator there.

[geno5150 168]

http://www.cigna.com/assets/docs/health-care-professionals/coverage_positions/mm_0051_coveragepositioncriteria_bariatric_surgery.pdf

According to CIGNA's medical policy, a BMI of over 40 is all you need to qualify as long as you have done the other hoop jumping. I am guessing this is a paperwork error and an appeal from the surgeon will fix it.

I know it may not seem like it, but insurance companies don't really try to disqualify as many procedures as they can as a rule. They are one of the most heavily regulated industries in the USA. Because of this, most of them employ more lawyers than doctors- that's where all the red tape comes from.

[honeycomb822 3]

It is true that big hospital's do have insurance coordinators, but what is not mentioned is when your partial denied, need more info. or outright denied the patient has to initial all appeals. The hospital will get the info. but my case proves even with the doctors doing the right thing, a patient still their own best line of defense.

[honeycomb822 3]

In reply to Geno....though many believe as you do that the insurance companies have these regulations, that in my case is not true. BC/BS in NH is considered a private insurance for my husband's company...they answer to no one even the government. I was beyond shocked when I found this out. This nasty little secret is the reason many companies can get away with their crap.

[Need-a-Sleeve 211]

All insurance carriers fall under some type & extent of state & federal regulation. That said, if the policy & claims are paid for by the employer, they can do a lot more with what they say is approved or not.

Ginger, Geno is right, file an appeal (most want it in writing) and then get in touch with the insurance coordinator at the surgeon's office. If they don't know, call your customer service number, write down the name of everyone (dates & time) of who you talk to. Ask for a supervisor & ask what you need to qualify. Most will tell you!

[honeycomb822 3]

I to thought this was true but it is not. in NH the BC I deal with does not have to answer to the state or fed. governmemt. I know you may well disagree but having just fought this battle and having a fed. government employee call me and tell me this information I was shocked. So as sad as it maybe, believe it or not....all insurance companies do not ahve to answer to anyone but themselves. Please look this up and you will see that it is indeed another sad state of affairs with insurance companies and having been told i first needed more info. an was then was turned down, I felt she should not the worst as I have just been through it.

On a lighter note, I noticed our surgery date was the same congrats and I to just had my first appt, and I have also lost 10lbs.

[Need-a-Sleeve 211]

I to thought this was true but it is not. in NH the BC I deal with does not have to answer to the state or fed. governmemt. I know you may well disagree but having just fought this battle and having a fed. government employee call me and tell me this information I was shocked. So as sad as it maybe' date=' believe it or not....all insurance companies do not ahve to answer to anyone but themselves. Please look this up and you will see that it is indeed another sad state of affairs with insurance companies and having been told i first needed more info. an was then was turned down, I felt she should not the worst as I have just been through it.

On a lighter note, I noticed our surgery date was the same congrats and I to just had my first appt, and I have also lost 10lbs.[/quote']

I am going to have to respectfully disagree. I have worked for health insurance carriers for nearly 20 years and even at the lowest form of regulation--they must be licensed to sell policies.

[honeycomb822 3]

That is fine..we all have our differences, I know what I have just been through and actually have paperwork to prove what I am saying. You actually can call the NH State Board of Insurance and they will tell you that Anthem BC/BS of NH maybe liscenced but are not regulated.

This was not meant to cause disagreements but to try and helper understand that no matter the reasons, do not let the insurance company make you feel like giving up. Bottom we are all here to help each other through the struggles tears and anger we feel when insurnace companies turn our worlds upside down. Would you not agree?