Are you good at understanding insurance?

[breprih 96]

I have Cigna. Here is a little background.

I had the lap band surgery in 2009. Initially went from 252lbs to 149lbs and now and back up to 202lbs. This past Friday I had my initial consultation for the sleeve revision surgery. The nurse practitioner is concerned that because my BMI is under 35 that insruance won't cover the sleeve. I called my insurance and they said my plan definitely covers bariatric surgery. They gave me this link. If you look at page 4 it talks about the revisional surgery. I don't see anywhere that it states my BMI must be 35 with a comorbitity. Do you ? For an initial surgery yes (page 2) but not the revisional surgery. You can take a look at the link if you want to see everything but here is a picture of page 4. Anyone who really understands this stuff I'd really appreciate your insight! Insurance confuses me so!

https://cignaforhcp.cigna.com/public/content/pdf/coveragePolicies/medical/mm_0051_coveragepositioncriteria_bariatric_surgery.pdf

[Deleted Account 151]

I'll preface this by saying that I know nothing about insurance.

I don't see anything about BMI, but it does say that the revision would be due to some sort of defect.

Unless I'm reading incorrectly, you lost over 100 lbs., and there is no defect.

Like I said, I know nothing. 😀 I do hope you get the surgery.

[breprih 96]

Just now, Elise24 said:

I'll preface this by saying that I know nothing about insurance.

I don't see anything about BMI, but it does say that the revision would be due to some sort of defect.

Unless I'm reading incorrectly, you lost over 100 lbs., and there is no defect.

Like I said, I know nothing. 😀 I do hope you get the surgery.

Thanks for the reply! I didn't write about all the issues I am having with my band but yes there are some defects. In general greater than 50% of people banded have problems with it causing them to gain weight back. I also have severe heartburn and daily vomiting due to the band. I'm having an upper GI and upper endoscopy to determine what is wrong with it for sure. However I did have an unrelated surgery in 2015 and that Doctor took a look at the band at the time and said that she didn't think it looked right. So, we're expecting that it probably "slipped".

[Deleted Account 151]

It sounds like you certainly qualify! No question about it! Please keep us informed about your insurance. For me, it was so difficult to not know if I was approved or not. ❤️

[breprih 96]

1 minute ago, Elise24 said:

It sounds like you certainly qualify! No question about it! Please keep us informed about your insurance. For me, it was so difficult to not know if I was approved or not. ❤️

Thanks! I'll let you know!!

[OutsideMatchInside 10,166]

@breprih

I don't think you would qualify by reading it unless your Dr carefully words your letter with some sort of band technical failure.

You originally lost all your excess weight, down to a 24/25 BMI. That is a weight loss success story That exceeds the 50% of excess weight. Your regain is more than 2 years post-op.

Quote

† In the absence of a technical failure or major complication, individuals with weight loss failure ≥ two years following a primary bariatric surgery procedure must meet the initial medical necessity criteria for surgery. NOTE: Inadequate weight loss due to individual noncompliance with postoperative nutrition and exercise recommendations is not a medically necessary indication for revision or conversion surgery. Surgical reversal (i.e., takedown), revision of a previous bariatric surgical procedure or conversion to another bariatric surgical procedure for ANY other indication is considered not medically necessary.

After over 2 years you have to qualify using the same criteria as the inital criteria, so you need a 35 to 39 BMI with a co-morbidity.

Edited September 19, 2017 by OutsideMatchInside

[breprih 96]

13 hours ago, OutsideMatchInside said:

@breprih

I don't think you would qualify by reading it unless your Dr carefully words your letter with some sort of band technical failure.

You originally lost all your excess weight, down to a 24/25 BMI. That is a weight loss success story That exceeds the 50% of excess weight. Your regain is more than 2 years post-op.

After over 2 years you have to qualify using the same criteria as the inital criteria, so you need a 35 to 39 BMI with a co-morbidity.

Thanks for sharing your interpretation of this! It's so confusing. I'm not sure if they go by tje weight you lost or your current weight.

[OutsideMatchInside 10,166]

The best way for you to have your surgery covered at this point would be a Dr documenting that your band has slipped.

[breprih 96]

Just now, OutsideMatchInside said:

The best way for you to have your surgery covered at this point would be a Dr documenting that your band has slipped.

My thought too! I have an upper GI this week then I'll schedule an upper endoscopy after my consult with the surgeon 10/3.

[Diana_in_Philly 1,426]

A diagnosis of reflux from the upper GI or endoscopy appears to be enough to trigger it. But I would speak with the insurance coordinator at your doc's office and not the NP - she doesn't do the insurance paperwork. Those folks generally know how to word things to trigger coverage.

[erisp 28]

I completely agree with Diana_in_philly. I work for an insurer and it is all in how paperwork is worded!

HW 305, SW 265, RNY 8.17.17

[Nishax3 10]

Hi there I I'm not familiar with Cigna insurance however it will be best for you to contact a Cigna representative and ask them to explain your benefits. From what I read it seemed that if your primary care recommend the surgery then it is based on medical necessity which they should cover. Also if the site that you are going to do your surgery can also request an authorization but you will need a referral from your primary care.

Sent from my SM-N920P using BariatricPal mobile app

[Nishax3 10]

Hi there I I'm not familiar with Cigna insurance however it will be best for you to contact a Cigna representative and ask them to explain your benefits. From what I read it seemed that if your primary care recommend the surgery then it is based on medical necessity which they should cover. Also if the site that you are going to do your surgery can also request an authorization but you will need a referral from your primary care.

Sent from my SM-N920P using BariatricPal mobile app

[Nishax3 10]

Hi there I I'm not familiar with Cigna insurance however it will be best for you to contact a Cigna representative and ask them to explain your benefits. From what I read it seemed that if your primary care recommend the surgery then it is based on medical necessity which they should cover. Also if the site that you are going to do your surgery can also request an authorization but you will need a referral from your primary care.

Sent from my SM-N920P using BariatricPal mobile app

[breprih 96]

Thanks all! I'm pretty sure I'll be all set because they took Fluid out of my band last week and I'm already up a few lbs =(

That combined with the weight of my clothing is going to get my BMI up to 35 and I'm 90% sure I still have sleep apnea which is a comorbitity. =(