CIGNA..Pre-Determination of Medical Necessities

[lilbit08 0]

Ok I have Cigna Open Access Plan and I called them today and the rep. told me that my policy doesn't say whether it covers WLS or not. He said that whatever Dr. that I choose would need to call them and get Pre-Determination of Medical Necessities paperwork, fill it out and send it back in and then we can go from there....Anyone know what this means? Also, what is the 6 mnth period that most ins co's make u do and what if u loose weight during this time? Does it mean you are no longer eligible for ins to cover u? Someone please advise...

[MiniBand 0]

This article is worth a look to help you get the approval the first time:

http://www.obesitylaw.com/images/content/pdfs/Maximizing_Article.pdf

What I had to do was fill out this really long packet of info and then go to the Dr. and have them weigh me. Unfortunately most PCP aren't clued in about what to put for notes for this kind of surgery. I was supposed to go for 6 months. Well then I was denied. I wish I had read the article above. You may not have all these requirements but your Dr. office once they get the packet may be able to help more.

Hopefully someone with the same kind of ins. will chime in. I have PPO but I thought I would at least reply with that article. Good luck!

M

[lilbit08 0]

This article is worth a look to help you get the approval the first time:

http://www.obesitylaw.com/images/content/pdfs/Maximizing_Article.pdf

What I had to do was fill out this really long packet of info and then go to the Dr. and have them weigh me. Unfortunately most PCP aren't clued in about what to put for notes for this kind of surgery. I was supposed to go for 6 months. Well then I was denied. I wish I had read the article above. You may not have all these requirements but your Dr. office once they get the packet may be able to help more.

Hopefully someone with the same kind of ins. will chime in. I have PPO but I thought I would at least reply with that article. Good luck!

M

Thansk for the info! Looking over it right now!

[oscarel 0]

Lilbit08, I also posted in another thread you had. Check this link too CIGNA - Medical Necessity Definitions

When I started the long road to lapband with Cigna my first call to them they were able to tell me whether it was covered or not. You may have to contact your HR dept. to find out if it's included. Cigna also told me they wouldn't even start to look at paperwork until you've met all the requirements, psych, 6 month diet, nutritionist. Also I had just gone for my annual physical and I told my PCP that I was looking into this for obesity. So in the paperwork for the 2 years proof of obesity it was there and I didn't need to get another letter stating it was a necessity. I personally didn't have a lot of problems with Cigna. They approved me on the first submission, within 1 week of submitting, and they paid with no questions asked. I had my surgery done at AIGB in Richardson and I'd recommend them. My surgeon was Dr. Felts, but he's not with them anymore. They took care of all the paperwork, but you will need to double check what they do...

Oscar

Edited November 22, 2008 by oscarel

[Carrie_C 9]

I have the same type of insurance as you. You will have to do a six month diet if you haven't already. They now accept weight watchers, jenny craig, etc, they didn't when I was trying to get it approved. If you have done any of those diets, get the records. If you haven't had the 6 months, start on it now. You will need it before they will even consider it. You will also need a psy and nutrition eval. Your PCP will also have to write a letter of medical necessity. The doctor needs to put any comorbitites you have in the letter as well as how long you have been overweight. I think they require you to have been overweight for 2 years. As far as losing weight on the 6 month diet, they want you to lose so much percent, I can't remember the exact amount. I was lucky that my surgeons office helped a lot with the paper work. Once everything was submitted, it didn't take long for me to be approved, about 3 weeks. I haven't had any problems with them so far. Good luck!

[lilbit08 0]

I have the same type of insurance as you. You will have to do a six month diet if you haven't already. They now accept weight watchers, jenny craig, etc, they didn't when I was trying to get it approved. If you have done any of those diets, get the records. If you haven't had the 6 months, start on it now. You will need it before they will even consider it. You will also need a psy and nutrition eval. Your PCP will also have to write a letter of medical necessity. The doctor needs to put any comorbitites you have in the letter as well as how long you have been overweight. I think they require you to have been overweight for 2 years. As far as losing weight on the 6 month diet, they want you to lose so much percent, I can't remember the exact amount. I was lucky that my surgeons office helped a lot with the paper work. Once everything was submitted, it didn't take long for me to be approved, about 3 weeks. I haven't had any problems with them so far. Good luck!

thanks for the reply..so let me understand..ihave done weight watchers in the past but not for 6 mnths...the dr that i am using, i have been told that he is pretty good with helping u along the way..i know that u said they make u do a 6 mnth diet first, so how did u get approved in 3 weeks?

[Carrie_C 9]

I did the 6 month diet before I submitted everything for approval. Once I had everything done, it only took 3 weeks to be approved. You have to have everything done before you even submit it to be approved, including the 6 month diet, and the psych and nutrition evals. It has to be 6 consecutive months, you will have to start all over.

[Sooverit! 1]

This is never going to end with Cigna. Well I was denied 3x with the help of obesitylaw.com. They sort of cut me off after the 3rd denial. I had a too low BMI 37 without co mobidities the approve of. Went through the 6 month diet etc. Now it's still with in the year and I developed HYPERTENSION....I big green light for coverage and I am on MEDICATION for it..

Can I resubmit? My surgery is in 2 days....will I get reimbursed? Should I re schedule the surgery....(Don't want to )

[Carrie_C 9]

I wouldn't reschedule. They usually only pay if you have 2 comorbidities with a low BMI.

[Sooverit! 1]

Thank you Carrie...yikes! Cigna is unbelievable...I also read on the web site that they only cover if your co mobidity is not responding to meds. It's amazing how some folks are covered immediately. Well they are now at least covering all my tests and medications! Glad I didn't reschedule after all this!

best,

m

[Carrie_C 9]

They approved my surgery pretty quick, but my BMI was over 40. I think it is very hard to get them to approve it if your BMI is below that, even if you have several comorbidities. Good luck!