Seeking revision to DS...anticipating CIGNA issues

Hello ALL!

I had an RNY in 2000 and am just learning this past summer, via this board, that revisions are "a thing!" I  got insurance through my job this year because they had a plan that covered revisions.

My BMI is currently 44.9 and CIGNA requires a BMI of >50 for DS. I have lupus, arthritis, and systolic heart failure as my air co-morbidities.

The 64K questions is: Does that requirement mean for all DSers, or just first time DSers?

I have called the "1800 CIGNA" line 4 times now and the first three agents thought it meant only for first timers, were actually pretty confident of it and made a believer out of me. However, when I called today, another agent said no, it means for all bariatric patients. He had his manager to read over it and  the manager agrees. That stinks! There is room for ambiguity and a little confusion on the part of how the requirements are listed, I think.

Anyhoo, has anyone had any recent experience with battling CIGNA and how to proceed?

The guy today mentioned  a reauthorization and if it was denied to get the doctor to do a peer to peer call.  Do you think it is a BIG DEAL to ask for a peer to peer, or is it pretty common these days? Are there other things I should do first before requesting that?

I have an appointment with Dr. Ayoola (Frisco/Denton, TX) next Tuesday for an in initial consult and just want to know what to expect on my part and what to expect from his office and CIGNA.

All comments, suggestions, and advice are welcome!

Thanks so much!

First, regarding your policy, get a copy of your EOC (evidence of coverage) for yourself and read the sections on bariatric surgery in general and revisions in particular for yourself. No one should trust the word of some poor insurance company employee who may or may not interpret your policy correctly. You've already been down that road and learned that different people will give you different answers. No one cares about this more than you.

My guess, and I admit it's just a guess, is that you will indeed have problems getting approval, so also read up on what your appeals avenues are. Denials can be appealed, often with success. Where a peer-to-peer will fit it depends on how appeals are done through your insurer, so again, you need to know your policy and your rights.

Re: comorbidities - lupus is a separate medical problem, not a comorbidities. Comorbidities are diseases caused by being MO and which may or may not be improved or resolved by treating your MO. Lupus is serious but unrelated to being MO. Arthritis is a comorbidity if it's weight bearing joints. I don't know what you mean by systolic heart failure, so I'm not sure if that's a comorbidty or not. I'm not suggesting that these aren't all serious issues, just that not every medical problem is a comorbidity.

Dr Ayoola has an excellent reputation and definitely does the DS, but I have not heard that he's doing RNY to DS revisions. This is the more complicated and challenging type of bariatric surgery being done. It requires that the entire RNY be taken apart and returned to the original anatomy, and then the full DS being done. the risks are significant, and only a few DS surgeons are doing this operation. I'm not saying you shouldn't do it, just that you may not be able to have it with Dr. Ayoola and you may need to travel. I would be very, very wary about any other surgeons in your state for this operation. There are too many stories out there where people have gone to other surgeons in TX for RNY to DS revision and ended up with something else instead. Your choice of surgeon is crucial for this type of surgery.

I will also send you a pm.

Larra

Larra, 

Thanks so much for taking the time to post and for the information in your pm. I will definitely look into what you have suggested. Thanks for correcting me on my comorbids. I have a family history of diabetes and hypertension from my parents and my siblings. My mom also had COPD and I suffer with shortness of breath and arthritis in weight bearing joints as well as in my low back. 

I have read over my policy and feel I definitely should qualify---with or without a BMI of 50 or greater, but for a better quality of life! 

My wiiFit age is 92! (more than double my real age!) That should count for something!