Denied By Cigna

[lorimac 1]

I got a call from the surgeon's office today. The girl said they denied me bacause my BMI is not 50 or over. Cigna's website says the BMI has to be 40 or over. I didn't get any help from the office person. She tried to talk me into the gastric bypass, which they WILL cover, by the way. She didn't offer to call them or re-file. I asked about a peer-to-peer review, and she said the he wouldn't do it because my BMI isn't high enough. What do I do? Gain weight? Call them? See another surgeon who will fight harder for me? I am at a loss. I know Cigna is tough, but I did everything I was supposed to do and I meet the guidelines on their website. Anyone have any suggestions? Thanks for the help. I am frustrated right now.

[Ready4success 380]

Call Cigna and talk with a rep about what the requirements state on the website. Do you know which Cigna you have? It wouldn't happen to be Open Access Plus, would it? I have the most knowledge about that plan. A denial doesn't mean it's impossible. Good Luck.

[prettysleeved1 173]

Did you call Cigna yet and inquire?

[ProudGrammy 8,322]

you have a bunch of phone calls ahead of you

i thought most insurance companies require a 40+ BMI not 50+

do you have any co-morbities?

can't figure why the surgeon isn't willing to do your WLS

be persistent with the insurance company

i would definitely talk to another surgeon if cigna is in your corner

most insurances cover the lapband and gastric bypass WLS

the sleeve has slowly emerged and being covered more often

don't settle............it might take awhile but................

good luck

[mysunflower621 69]

When I was trying to get approved for the band, I got denied 3x by Cigna and I got 3 differnt stories from them and the office. My office did fight for me and I ultimately got approved by Cigna for the band. When I changed my mind and wanted to go for the sleeve, although we had to resbumit everything, Cigna did approve me within a week. That being said you need to read what they have on their website for your plan and what the requirements are. Call Cigna and ask them why it was denied specifically. You should be allowed up to 2-3 appeals and then the 3rd and final appeal goes to a 3rd party who reviews everything. If they will cover bypass, they certainly should be covering the sleeve!

If your doctor's office isn't willing to work with you and the insurance company to fight for you, then I say find another doctor who is just as reputable but willing to do what it takes and knows how to work the insurance companies! A good case manager knows exactly what is needed and how to fight it if you are truly meeting the requirements and being denied.

Good luck, keep fighting.. it's the squeaky wheel that gets the oil!

[lorimac 1]

I am beginning to question the people who work for my surgeon. The girl at the office told me the wrong reason for my denial. She saw BMI over 50, but that was for the DS! I can't believe she got it mixed up!

I got a copy of the denial letter, and it says "The above request has been denied by the Medical Director. Reason: CATEGORY OF TREATMENT: Inpatient". Does this mean because I have to spend the night they are denying?

[janda927 9]

I was told it's much easier to get approved for lap band since its an ambulatory service (outpatient). Ins approve sleeve less offen since considered an inpatient service. Good luck, it will happen. I'm in same boat and planning on fighting my ARSH off.

[Neta912 14]

I was just approved this week after originally being denied. The coordinator told me that Cigna can be difficult. Just find out exactly what you need and resubmit the info. Cigna actually wanted me to have a clearance for surgery before they would approve it. I am scheduled to be sleeved on October 11th!!!

Try again and good luck!

[Ready4success 380]

I am beginning to question the people who work for my surgeon. The girl at the office told me the wrong reason for my denial. She saw BMI over 50' date=' but that was for the DS! I can't believe she got it mixed up!

I got a copy of the denial letter, and it says "The above request has been denied by the Medical Director. Reason: CATEGORY OF TREATMENT: Inpatient". Does this mean because I have to spend the night they are denying?[/quote']

I would call Cigna and ask them to explain the reason for denial. Maybe they wanted it coded as outpatient or a 23 hour observation. Insurance companies deny people for such silly reasons.

[billyvmom 128]

I agree call everyday if you need to. I have Cigna and was sleeved on sept 4 they approve it all the time but, can be nitpicky about the ins and outs. Don't get discouraged get focused on what little thing they need to get you approved.