From Cigna Denial to Self Pay to Approved!!!!

ML in VA · August 1, 2008

Okay, so I started this journey in May 2008 after getting my PCP to agree that lap band is definitely something that I should consider, even though I had no comorbidities.

I had done a 6 month diet with my PCP (I had missed 2 months), nutritional consult and psych eval and had documented my 5 year weight history. Everything was submitted to Cigna - within 6 weeks I was denied due to BMI being 41.5 but not for 2 years and lack of 6 month diet. I resigned myself to the denial, but shot off a quick, emotional appeal letter (unbeknowst to my surgeon) that basically stated I know I missed 2 doctors visits, but that was only because I was losing weight and yes, my BMI fell below 40 in the past 2 years, but that was due to a liquid diet that I tried. I also stated that I met all the requirements and reattached all of the docs previously sent and advised them why I felt I needed the surgery (family history of diabetes, high blood pressure, cholesterol and heart disease) and also documented my battle with weight for the past 10 years and basically said that Cigna coul expect to pay the claims associated with these diseases that would surely come my way.

I prepared to self pay and borrowed 17K from my 401K. Surgery date was set for 8/14 and I was resigned to pay this large sum - even though I can't afford it.

2 days ago I received a call from Cigna's medical director assistant, indicating that they needed my nutritional consult resent. I faxed them this info and advised my surgeon's office what they asked for. They chuckled and said it was already sent and this is a stall tactic that insurance company uses. Today, I received a call from the medical director's assistant..APPROVED!!

Moral of the story is sometimes a heartfelt appeal with the supporting docs works; don't give up. I hope my story helps someone.

ML in VA

cw 289

U_go_gurl68 · August 1, 2008

Much congrats to you. I know you must be ecstatic. Can't wait to hear about your other victories once you are banded.

I had to use money from my 401k, since my insurance wouldn't cover my surgery. My bmi was too low and I didn't have too many problems, mainly just a bad family history. They would only for the surgeons around where I live and to top that off, the surgeons wouldn't do the surgery if I didn't meet the same guidelines as they use for insurance purposes.

I am happy it all worked out for you. I will be paying this money back for the next 5 yrs, but it was an investment well worth it.

Best wishes,

Stephanie

agw504 · August 2, 2008

Congrats!!! I have Cigna HMO also but fortunately did not have to go through that!!! Where in VA are you? Who is your surgeon? I am in Richmond and having surgery by Dr Schroder at St. Marys Hospital. Would love to chat with you more. Congrats again!:wink2:

ML in VA · August 2, 2008

Thanks so much, Stephanie. I think I may to keep some of my 401K money out for the new wardrobe that I'll be sure to need. I can't wait!

ML in VA · August 2, 2008

Congrats!!! I have Cigna HMO also but fortunately did not have to go through that!!! Where in VA are you? Who is your surgeon? I am in Richmond and having surgery by Dr Schroder at St. Marys Hospital. Would love to chat with you more. Congrats again!:wink2:

Hi Angela, I'm having my surgery by Dr. Terracina at Sentara Careplex in Hampton. I would love to chat as well!